The Exercise Myth

Dr Henry A. Solomon, M.D.

Now(1984)practisescardiologyinNewYorkCity,whereheis
onthefacultyofCornellUniversityMedicalCollegeandan
attendingphysicianatNewYorkHospital.Helectures
frequentlyandpublishesnewslettersdirectedtocolleaguesand
tocardiacpatients.

Introduction

Thousandsofpeoplebelievetheyarejoggingtheirwaytogood
healthandalongerlife.Thousandsmoreflocktotenniscourts,
gymnasiumsandexerciseclasseshopingtoescapethenumber
onekiller,heartdisease.Exerciseistheprimepanaceaofour
time:millionsofdollarsarespenteachyearonexercise
equipment,clothingandadvice.
ArewethevictimsoftheExerciseMyth?Almostnothing,
cardiologistHenryA.Solomonsays,youhavebeentoldabout
thebenefitsofexerciseistrue.Vigorousactivitycannotprevent
heartdiseaseorslowitseventuality.Exercisehasnoeffecton
longevity.Youcanbehealthywithoutbeingfit.Youcanalsobe
fitandstilldevelopfatalheartdisease.
DrSolomonexplainsclearlythefollyoffads;heshowsthe
dangerinstrenuousexertion;heconfirmstheunreliabilityof
stresstests.
Whattodo,then?Forthosewhowishtoexerciseforfitnessor
forweightlossorsimplyforpleasure,DrSolomonoffersasane
way.

The Exercise Myth by Dr H Solomon

1. The Exercise Market Place

Iseethemearlyinthemorningonmywaytowork.Iseethem
frommyofficewindowsduringtheday.Andintheevening,
theyarestillhustlingbackandforth:womeninstylishgear
hurryingtoexerciseclass;middleagedmenhuffingtoandfrom
CentralPark;peopleofeveryageanddescriptionpantingand
sweatingtheirwaytotoday'sversionofthehealthylifestyle.
Iamacardiologist,aseagertosaveothers'livesastheyareto
holdontotheirown.Andyetforallmyconcernandtheireffort,
exercisersareaslikelyasanytowindupamongmypatients.
ThoseexercisersIgettosee,andperhapstohelp,areonlyafew
ofthetensofmillionsintheUnitedStateswhonowrunorjog
regularly,andthemerestfractionofthosemanymillionsmore
inthiscountryandaroundtheworldwhohavetakenupthe
bannerofvigorousexerciseingeneral.Theyarethe
representativesofallthosewhohaveboughtthemistakenidea
thatstrenuouseffortpromoteshealthandlongevity.Theyseek
anunattainablegoal.Theyarethevictimsoftheexercisemyth.
Nooneknowsexactlyhowmanyindividualsexercisehardand
ofteninthebeliefthattheyaredoingthemselvesgood.
Althoughthereareprobablymillionsofbelieverswhoworkout
ingyms,onhandballcourts,attennisclubs,indanceclassesand
othermeetinggrounds,runnersaretodaythemostvisibleof
thosewhoincorporatevigorousandoftenpunishingexercise
intotheireverydaylives.Youcangetanimpression,atleast,of
howmanyjoggersdoggedlypoundthepavementofcitystreets
ortrottheshouldersofsuburbanroadsbyjustlookingaround
youduringthepopularearlymorningandafterworkhours.
Theirnumberhasbeenguessedtobe30million.
Morereliablenumbersexistfor"real"runnersthosewhorun
marathonsorenterlesserraces.Therearenowabout300
organizedmarathonsrunyearlyaroundtheworld.FredLebow,

presidentoftheNewYorkRoadRunnersClub,refersto
"marathonfever"indescribingthespreadofsuchorganized
racing.TheBostonMarathonhasabout8,000registered
entrants;another8,000unregisteredrunnerstheregistered
racerscallthem"bandits"usuallyjointherace.Thelast
L'EggsMiniMarathon,a6.4mileraceinNewYorkCity,
registeredabout6,500womenfrom34statesand8countries.
TheincreasinglypopularMontrealMarathonnowhasabout
10,000entrants,andtheNewYorkMarathon,perhapsthemost
famousraceofall,nowattractsabout17,000registrants.One
wouldhavetoguessthattherearehundredsmaybethousands
of"mere"joggersornovicerunnerstoeveryregisteredracer.
Andtheremustbeatleastasmanypeoplewhostrivefortheir
weeklydoseofexerciseinotherways.
Informerdays,thehealthiestformofexercisewasthoughttobe
adaily"constitutional"amodestlybriskwalkthatcouldbe
accomplishedwithoutspecialgearandcertainlywithout
panting.We'vecomealongway,butwhy?Runnersrunand
exercisersexercisebecausesomanypeoplehavetoldthemit's
goodforthemphysically,emotionally,sociallyandeven
spiritually.Thedistinctionsbetweenvariousbenefitsarerather
blurredtojudgebythebooksandmagazinesthatpromote
exercise.Self,asmashingsuccessonthenewsstandsthesedays,
isdescribedbyitseditorasamagazineof"physicaland
emotionalwellbeing."Thetitlesofothernewentriesintothe
fieldNewBody,AmericanHealth,Shape,Fit,Spring
promiseablendofradiantskin,lithefigure,athleticprowess
andexcellenthealth.Traditionalmagazines,whetherdevotedto
motherhoodorfashion,havedramaticallyalteredtheirformat
andthrusttoreflectthenewemphasisonexercise.
Socialpressuretoparticipateinthemovementisquitereal.
You'reaslikelytohearmentionof"aerobics"and
"cardiovascularfitness"incocktailpartyconversationasyou
aretohearaboutthelatesttheatricalhit,newrestaurantor

fashionnews.Andyou'reexpectedtorespondwiththeright
knowledge,jargonandenthusiasm.
Knowledgeandjargonaren'thardtocomeby.Bookstore
shelvesarefilledwithexercisebooks,treatisesonhowtorun
andwhentorun,onstrengtheningyourbody,onchangingitand
makingitbetter.Theenthusiasmiscatching.JaneFonda's
WorkoutBookwasnumberoneontheNewYorkTimes
bestsellerlistfor51weeksinsomespotonthelistfor92
weeksandJamesFixx'sbestsellingbook(1)onrunningsold
nearly1millioncopiesinhardcoveralone.Itsauthor,whosaid
hecould"showyouhowtobecomehealthierandhappierthan
youeverimaginedyoucouldbe,"becamehighlyvisiblein
televisioncommercials.
Strongbusinessandcareerpressuresareoftenexertedtomake
peopleconformtothedogmaoftheexercisebelievers.Subtle
andnotsosubtleinfluencesmaycompelotherwiseunwilling
individualstoparticipateinphysicalactivityprograms.In1980,
over3,000businesseswereprovidinghealth!fitnessprograms
foremployees.Somecorporationshavemadelargefinancial
investmentsinbuildingtheirownexercisefacilitiesfortheuse
ofalltheirpersonnel.Othercompaniespayconsiderablesums
ofmoneytooutsideexercisefacilitiesfortheirexecutives,and
individualparticipationintheprogramsmaybeperiodically
reviewed.RunnersHandbookreportedthatinonemajor
corporation,employeeswhodon'texercisearegently
admonishedbytheircolleagues.Nowonder;$5billionisspent
yearlyonemployeefitnessprograms,(2)andnobusinesslikesto
seeitsinvestmentswasted.
TheCorporateChallengeSerieshasbecome,exceptfortheNew
YorkMarathon,thelargestraceorganizedbytheNewYork
RoadRunnersClub.Itreceivesalotofmediaattention,and
competition,whilefriendly,isintense.ThelatestCorporate
Challengeraceattracted8,000runners.Asdescribedby

DeborahGreene,racedirectorofthe1980Manufacturers
HanoverCorporateChallenge,inNewYorkRunningNews,
"afteraharddayattheoffice,tiredcorporateworkers,from
officeboystopresidents,wendedtheirwaytowardCentralPark
...foracompetitiverace.Theycamedressedtorun,parading
thestreetsinshorts,runningshoes,andsingletsemblazoned
withthenamesoftheircompanies.They...huddledunderthe
signsorbannersoftheircorporateteams."(3)
Whetherfacilitiesandprogramsforexerciseandcompetition
arefosteredbytruebutmisplacedbenevolentconcernonthe
partofcorporatemanagementorbytheunprovenexpectation
andhopeofgreateremployeeproductivity,thefactisthatthe
managerorexecutivewhodoesn'tseethesecorporate
commitmentsasanunspokencorporatephilosophyorcommand
mayberiskingcareeradvancement.Withinone'sbusiness
world,aswithinone'sneighborhood,being"into"exercise
undeniablyconveysacertainstatus.
Televisionhashadanimportantinfluenceonthefitness
phenomenon.Theglorificationofwinnersandtheintense
publicitysurroundingwhatarelargelymediaeventstherunner
hasbeencalledthe"darlingofthemedia"alloweventhe
amateurtofeelspecial.Whereasregularnetworktelevision
blazedthetrailbyincreasingcoverageoftheprofessionaland
trainedathlete,cabletelevisionfocusesheavilyontheuntrained
amateur,thatpersonathomewhocouldbeyou.TheCable
HealthNetwork,forexample,isarelativelynewtwentyfour
hourcabletelevisionchanneldealingonlywithhealthand
fitness.Awiderangeofprogramsisbroadcast,withtheheaviest
emphasisonexercise.
Theconsensusthatexerciseisbeneficialreflectedinthe
social,careerandmediapressurestoexercise,andthecoupling
offitnesstohealth,beauty,sexual,socialandbusinesssuccess
isboththeproductof,andtheimpetusfor,avarietyof

extravagantandunfoundedclaimsaboutwhatexercisecando
foryou.Manypromisemedicalhelp.Ahighlysuccessful
exercisecenterinNewYorkoffersa"systematicprogram
designedtostrengthenyourheart......andhelpreduce
coronaryriskfactors...."Aprofessionaldanceroffersacourse
inaerobicsthatwill"strengthenyourcardiovascularsystem..."
andhaveyou"thoroughlyenjoyyourreturntogoodhealthanda
goodfigure."Anationwidenetworkofrehabilitationcentersfor
cardiacpatientspromotes"safe,supervised,telemetry
monitoredexercisetherapy..."throughwhich"you'llfinda
newwayoflife...anatmosphereofhope,notheartbreak."
Evenamanufacturerofcornoiloffersan"informationpacked
booklet"inwhich"differenttypesofexercisesareevaluatedfor
fitnessandcardiovascularhealth."Andadentistsuggeststhat
you"jogover"tohisofficeforspecial"dentistryfortherunner."
Promisesofmedicalhelpoftentendtoshadeintopromisesof
spiritualrenewal.Oneexercisecentercoinsanewterm,
"biofitness,"andoffers"atailormadeprogram,basedon
individualneeds,tointegratethemindandbodyinagetwell
getbettergoal."
Perhapstheexaggerationofbenefitsandblurringofclaimsare
bestsummedupintheadvertisementofalargesportinggoods
store,whichpromisesthatitsindoorjoggingtreadmillfosters
"CardiovascularHealth,AerobicFitness,FacilitatesSleep,
BetterBalance,MuscleStrength,FeelingofEuphoria,Better
Health,IncreasedStamina,WeightControl."
Nowonderpeoplearewillingtopayforsuchapanacea.And
paytheydo.Onthebasisofamazingclaims,thepublicis
spendingenormoussumsofmoneyforexerciseclothing,
equipmentandprograms,andexercisehasbecomeverybig
business.OnWallStreet,itwouldbecalleda"growthindustry."
Salesofjoggingshoes,forexample,havemorethandoubledin
thelastfiveyears,althoughsomemaybuythemmorefor

comfortorstylethanforrunning.Oneoutofeverythreepairsof
shoessoldintheUnitedStatesissneakers.TheNikeCompany
alonesoldabout13millionrunningshoesin1983;andtheir
totalsales,nowincludingotherapparelaswellasshoes,arein
thehundredsofmillionsofdollars.Thesheernumberof
differentrunningshoesisastounding.Afewyearsago,a
leadingrunners'magazinelistedaboutadozenbrands.The
latestavailablereportlistsoveronehundred.Thenumberof
modelsmustbestaggering.
TheNationalSportingGoodsAssociationestimated1982sales
toindividuals(notcountinganyinstitutionalsales)ofathletic
equipment,includingbarbells,treadmills,trampolines,exercise
bicycles,rowingmachinesandjumpropes,tobe$499.4million.
Individualsbought42.2millionpairsofexerciseshortsfor$374
million.Theyspent$212milliononsweatshirts,and$385
milliononwarmupsuits.ThomasB.Doyle,directorof
informationandresearchfortheassociation,callsthesefigures
conservative,andestimatestheyare25percentlowerthan
actualsalesfigures.
Inkeepingwiththecouplingofexercisetobeauty,statusand
success,thebusinessofclothingexercisersishighfashionby
now.Theterm"lockerroomchic"hasbeencoinedandis
actuallythenameofthefashionsectionofanewmagazine.
Warmupsuits,runningshorts,socks,shirts,hats,visors,
sunglasses,headbands,areallpromotedviaaningeniously
successfulamalgamoffashionandfitness.
Runnersandotherexercisersarejustastrendyandslavishto
fashionasanyoneelse.Ofcourse,muchofthefashionemphasis
hasbeendirectedtowomen,andanumberofnewproductshave
beencreatedtocapitalizeonthedemand.Sincethenumberof
womenathleteshasincreasedgreatly,manufacturershave
introducedmorethanadozen"sportsbras"inthepastfew
years."Joggers"bounce"and"joggers'nipples"arenowterms

ofcommonparlance."Whateveryoursport,"onebrandclaims,
"there'sabra...."Theyoffertheracquetbraandtheactive
womanexercisebra,aswellastherunningbra.
Mostbelieversinexercisedenythattheirdevotiontophysical
activityisgreatlyinfluencedbyadvertisingpromotion,socialor
careerconsiderations.Theyclaimtobeimmunetosuch
blandishmentsdespitethemoneyspenton"selling"exercise
throughtheallureofitsassociationwithbeautyandsuccess.My
ownobservationssuggestotherwise.And,anyway,getting
togetheronthecourtsorontherunningtrackprobablydoes
havesomesocialbenefits,justasexerciseamongexecutivesand
businesspeopleprobablydoesoffercareerbenefits.Ultimately,
though,exercisersofferamorehardnosedreasonfortheir
devotion.Theybelievethatvigorous,evenpunishingexercise
leadstobetterhealthandlongerlife.Theybelieve,specifically,
thatexercisepromotescardiovascularhealthandprotects
againstheartattack,theleadingcauseofdeathinthiscountry
andinotherindustrializedsocieties.
Theideaofimmunityfromcardiovasculardiseasebyvirtueof
vigorousexercisehasbeenthefoundationuponwhichinterest
andparticipationinexercisehavegrown.Achievingalonger
lifeandahealthieronethroughexerciseisthesingleconstant
threadwoventhroughthehistoryoftherecentexercise
revolution.
Thisismyconcerntheclaimsoflongevity,improved
cardiovascularhealthandimmunitytoheartdisease.Asa
physician,Imayholdapersonalopinionaboutthesocialfringe
benefitsofexercise,butnotaprofessionalone.Asaphysician,
however,Ioughttohaveaprofessionalopinionabouthealthin
general.Andasacardiologist,Imust,anddo,haveastrong
opinionaboutthespecificrelationshipofexerciseto
cardiovascularhealthandlongevity.

Physicianshavehadamajorroleinthegrowthandmaturingof
theexerciserevolution.Whetherthemedicalprofessionreally
startedtheexercisecrazeorsimplyjoinedthegrowing
movementisarguable.Doctorshavecertainlyputtheirown
musclebehindtheexercisebandwagonandenthusiastically
leapedaboardasitgotrolling.Themedicalprofessionprovides
alegitimacyforexercisewhereotherwisetherewouldbenone.
Scienceisthoughtsomehowtobeabovefaddism,and
physicians'interestsarethoughttobepurelyscientific.When
doctorssanctiontheexerciserevolution,theaccompanying
commitmentsofmoneyandtime,aswellasanyriskstohealth
andsafety,thenbecomeacceptable.
Thefirstmajormedicalreferencetothepotentialhealth
promotingqualitiesofexercisewasastudyofLondontransit
workersconductedbyJeremyNoahMorris,oftheMedical
ResearchCouncil,LondonHospital.Inanarticleentitled
"CoronaryHeartDiseaseandPhysicalActivityofWork,"
publishedin1953intheEnglishmedicaljournalLancet,Morris
andhiscolleaguescomparedtheamountandseverityof
coronaryheartdiseaseinLondonbusdriversandinbus
conductors.Theyobservedthatthemoresedentarydrivershad
morecoronarydiseasethandidthemoreactiveconductors.
Theyconcludedthatphysicalactivityoffersprotectionfrom
coronaryheartdisease.(4)
Therewasnogreatpublicreactiontotheappearanceofthis
technicalpaperinascientificjournal,butithadconsiderable
impactonthemedicalprofession,whichsawinitanew
glimmerofhopeforthepreventionofheartdisease.Tothisday,
Morrissstudyisconsideredalandmark,itsconclusionswell
knowntomostphysicians.
AfterthepublicationofMorris'soriginalpaper,asteadystream
ofarticlesconcerningthepossiblehealthbenefitsofphysical
activitybegantoappearinmedicaljournals,keepingexerciseas

atopicofmedicalconcernatahighlevel.Meanwhile,a
diagnostictestwascomingintocommonuse,anditlulled
doctorsintobelievingtheycouldtherebydiagnosethecondition
ofapatient'sheart,andcouldeventellwhetherexercisewas
safeforthatperson.ThiswastheMasterTwoStepTest,named
foritsdeveloper,Dr.ArthurM.Master,ofNewYorkCity,who
introducedthetestinabout1925andlaterreportedhisresultsin
leadingmedicaljournals.
Theideaunderlyingthisfirststresstestwasthatabnormalities
oftheheartthatwerenotapparentatrestcouldbecomeevident
underconditionsofphysicalstress.Inotherwords,physical
stressexercisecouldprovokeabnormalcardiacresponses.
Sincetheheartworksharderduringactivity,physicaleffort
couldbeusedtobringouthearttrouble.Conversely,ifphysical
stressdidnotprovokeabnormalities,thenthepatient'sheart
couldbeconsiderednormal.Thelogicalcorollarywasthata
normalperformanceonthestresstestmeantthatphysical
exercisewassafe.
Astimewenton,refinementsinexercisestresstestingwere
made.InadditiontothesimplestepsusedintheMasterTwo
StepTest,treadmillsandexercisebicyclesweredeveloped.A
steadypromotionaleffortbegantobedirectedatphysicians.
Manynewcompaniesmanufacturingexercisetestingand
monitoringdevicessprangup.Soon,theageofcomputer
assistedandcomputerdirectedstresstestingarrived.Thenewer
devicesarehighlysophisticatedandcomplexcomparedwiththe
originalTwoStepdevice,andconveyamuchgreatersenseof
diagnosticprecisionandaccuracy.Manufacturingand
marketingeffortstodayarestrongerthanever.
Ifthescienceandtechnologyofmoderndaystresstestingare
somewhatconfusing,eventomanyphysicians,thefinancial
incentivesareclearer.Sincestresstestingisacomplicatedand
potentiallyriskyprocedure,anddoestaketime,feesarehigh.

AnexercisestresstestinNewYorkCity,forexample,may
easilycostbetween$150and$250.Tomanyphysicians,fees
fromstresstestinginitsvariousformsrepresentasignificant
percentageoftheirtotalincome.Themarketingeffortsof
companiessellingexercisetestingequipmenttophysicians
almostalwaysprominentlyfeaturetheeconomicrewardstobe
gained.Everysaleseffortevermadetomebyacompanyselling
exerciseequipmenthasemphasizedhowquicklyIcanearnback
thecost.Thecompanyevenprovidesananalysisshowingjust
howfewtestspermonthareneededtobreakeven,andthenhow
manytoearnmultiplesofthepurchaseprice.Andsincethird
partypayersBlueShieldandotherhealthinsuranceproviders
covermuchofthecostofthetests,financialconsiderations
rarelydissuadepatientsfromhavingthetestsdone.
Moreentrepreneurialindividuals,recognizingthatincreased
volumemeansincreasedrevenues,haveestablishedexercise
testingcenters.Peoplecomeontheirownorarereferredby
physiciansorexerciseclinicsforstresstesting.Theseexercise
testingcentersareoftenownedoutrightbyphysicians.
Alternatively,physiciansmayhaveequitypositions,usuallyin
exchangeforservingas"consultants"or"advisers."
Stresstestingisactuallyonlyasmallpartofthefinancialreward
fromtheseexercisecenters."Supervised"exerciseprograms
representamuchgreaterfinancialreturn.Moreandmore,
cardiacpatientsarebeingadvisedtoparticipateinregular
exerciseprograms.Sincesome350,000peoplesurviveheart
attackseachyearandtherearealtogetherseveralmillioncardiac
patientsintheUnitedStates,thepotential"pool"ofsubjectsis
verylarge.Mostexercisetestingcentersalsorunsupervised
exerciseprograms;therevenuepotentialisobvious.
Morethan20"cardiacrehabilitationclinics"openedonLong
Island,NewYork,aloneinthelastfewyears.Asthefieldof
exercisetestingandsupervisedexerciseprogramsgetscrowded

andcompetitionisfelt,onewaytohelpinsureasuccessful
operationhasbeentodivideownershipamongseveral
physicians,whothenhaveanincentivetorecommendthe
programtotheirpatients.Onesuchcenteradmits,accordingto
theNewYorkTimes,that85percentoftheprogram'spatients
comefromshareholderphysicians.
Ofcourse,noteveryphysicianwhorecommendsexercisedoes
itoutofvenalityorsolelyforprofit.Doctorsthemselves
participateinvigorousworkoutsanddemandinggames.At
manymedicalmeetingstherearerunninggroupswhoare
accordedspecialstatus.Onemajorpharmaceuticalcompany
sponsorsminimarathonsforphysiciansandtheirspousesat
varousmedicalconventions.Theseracesfeaturetrophiesand
awards,and,asacompanyspokesmanpuns,"arejustforthe
healthofit."Doctors,despitetheirmedicaltraining,are
consumersjustlikeeveryoneelse,subjecttothesameexercise
ballyhooandhypeastherestofthepopulation.
So,everythinghascometogether.Theenticementofprofit,the
seductionsoffashionandstatus,andthelegitimacyofmedicine
allsupportthisamazingexercisephenomenon.Sohugea
bandwagonsfueledbytheprofitmotiveandweightedbya
populationworriedaboutitshealthandbelievingithasfound
theanswer,hasaterriblemomentum.Thesobertruthmaynot
beenoughtostopit,butthetruthshouldbestated:
Youmayenjoyexercise;itmaybehelpfulsocially;itmaymake
youlookandfeelbetter.Butalltherestismyth.
Exercisewillnotmakeyouhealthy.Itwillnotmakeyoulive
longer.Fitnessandhealtharenotthesamething.

2. The Heart of the Matter

Mostofusrespondeasilytothecommongreeting"Howare
you?''becausewehaveanintuitivesensethathowwefeelisin
fact,howweare.Ifwefeelwell,weanswerthatwe'refine,and
ifwedon'tfeelwell,wemayreplythatwearenotwell.This
intuitivemergingofhowwefeelandhowweare,however,is
quiteoftenincorrect.
Eveninastrictlymedicalsetting,peoplemaymistakenlyequate
howtheyfeelwiththeiractualstateofhealth.WhenIaska
patient"Howdoyoufeel?,"Iamseekingspecificinformation
aboutsymptoms.Whenpatientsreply,astheysometimeshalf
jokinglydo,"Youtellme;you'rethedoctor,"Isay,"Youtellme
howyoufeel;I'lltellyouhowyouare."Thepointanditisa
crucialoneisthathowwefeelisnotnecessarilyhowweare.
Howyouareisastatementofyourhealth,andhastodowith
thepresenceorabsenceofdiseaseorabnormalbodyconditions.
Howyoufeelisacomplexsummationofphysical,mentaland
emotionalfactorsthatisoftenindependentofyouractualstate
ofhealth.
Withregardtocardiovascularhealth,thedivergencebetween
howwefeelandhowwearemaybeespeciallystriking.Andthe
implicationsofthisdiscrepancybetweenfeelingandactuality
canbeserious.Howwefeelislargelydependentonwhatwe
canphysicallydowhatiscalled"fitness"buthowweare
mayhavelittleornothingtodowiththis.Fitnessandhealthare
distinctandindependentofoneanother.
Fitnessisdefinedbyyourabilitytodophysicalactivityorto
performphysicalwork.Itisameasureofyour"functional
capacity."Itdoesn'treflectthepresenceorabsenceofdisease,
andimpliesnothingabouttheactualhealthofyourarteriesor
yourheart.Cardiovascularhealthreferstotheabsenceof
diseaseoftheheartandbloodvessels,nottotheabilityofan
individualtodoacertainamountofphysicalwork.Youroverall
cardiachealthisdeterminedbytheconditionofvariousheart

structures,includingtheheartmuscle,thevalves,thespecial
cardiactissuesthatcarryelectricalimpulsesandthecoronary
arteries.Thehealthofcoronaryarterieshasbeenclaimedtobe
relatedtoexercise.
Coronaryarteriesarethosethatcarryoxygenatedbloodtothe
heartmuscle.Healthyarteriesaresmoothwalledandof
sufficientdiameterinsideforbloodtoflowfreelythroughthem.
Incoronaryarterydisease,orcoronaryheartdisease,thearteries
thatcarrybloodtotheheartmusclearenarrowedandobstructed
bydeposits,calledplaques,ofcholesterolandotherfatty
substances.Theheartmusclecells,likeallothercellsinthe
body,requireoxygentodotheirwork.Theheartdoesn'tgetits
oxygenfromthebloodinsideitbutfromthenetworkof
coronaryarteriesthattraveloverandthroughtheheartmuscle.
Thepathologicprocesswherebythearterywallsfillupwith
fattysubstancesandtherebynarrowthechannelthroughwhich
bloodflowsiscalled"atherosclerosis."Itisthemajor
abnormalityinwhatiscommonlycalled"hardeningofthe
arteries."Sincealloftheoxygencarriedtothebodytissues
travelsintheblood,anythingthatdecreasesbloodflow
decreasesoxygensupply.Whencoronaryarteriesareblockedor
narrowedbyatherosclerosis,notenoughbloodandthereforenot
enoughoxygenreachheartmusclecells.
Coronaryheartdiseasecanbe"silent"andproduceno
symptoms,oritcanmanifestitselfinseveralways,ofwhichthe
mostcommonare:thechestpainandbreathlessnessofangina
pectoris,theevenscariereventofaheartattackandandthis
maybethefirst"symptom"suddendeath.Theseareabout
equallycommonasthefirstwaycoronaryarterydiseasemakes
itspresenceknown.Bythetimeoneoftheseoccurs,the
pathologicprocessofatherosclerosishasprobablybeengoing
onforsometime.
Anginapectorisliterallymeans"stranglinginthebreast."Those

wordsaccuratelydescribetheconstrictingchestpainthatgripsa
personwhenthereisatemporarilyinadequatebloodsupplyto
heartmusclecells.Noteverypatienthasthistypicalsymptom,
however.Thepersonmayinsteadfeellesscrushingpain,a
sensationofburningorpressure,aswellasbreathlessness,
weakness,faintnessorfatigue.Duringananginaattack,when
bloodandoxygensupplyarelessthantheheartneeds,heart
musclecellsaretemporarilyinjured.Ifthebloodandtheoxygen
supplyareincreased,ortheheartmuscle'sneedforbloodand
oxygendecreases,thenthecellsrecoverfrominjuryandthe
symptomsgoawaycompletely.
Aheartattack,knownmedicallyasa"myocardialinfarction,"
representsactualdeathofsomeheartmusclecells.Whena
coronaryarteryissonarrowedthatthebloodsupplyisvirtually
cutofftoanareaoftheheartmuscle,theseverelyoxygen
deprivedheartmusclecellsarepermanentlyinjuredanddie.
Anginapectorisandheartattacksarereallypartofthesame
problem,butinanginathebloodandtheoxygensupplyarenot
soinadequaterelativetotheheartmuscle'sneedsastheyareina
heartattack.Mostinitialheartattacksarenotfatal,butifthey
areextensiveenoughorcausesevereirregularitiesoftheheart
rhythm,theycancausedeath.Subsequentheartattacksareoften
moredangerousbecausethenewdamageissuperimposedon
theold.
Suddencardiacdeath,thethirdcommonmanifestationof
coronaryheartdisease,isusuallyduetoanarrhythmia,or
irregularityoftheheartbeat.Therearemanykindsofinnocuous
arrhythmias,andmanynormalpeoplehavethem.Onlyonetype
ofarrhythmiaisusuallyquicklyfatal.Italmostalwaysoccursin
peoplewithsomeseriousformofheartdisease,mostusually
coronaryarterydisease.
Thesethreeexpressionsofcoronaryarterydiseaseangina

pectoris,heartattackandsuddencardiacdeatharebyno
meansmutuallyexclusive.Anginapectoris,forexample,often
precedesaheartattack,althoughitmayfirstoccurfollowing
one.Suddencardiacdeathmayhappenwithoutwarning,butit
alsooftenfollowsaheartattack.Andalltheseexpressionsor
noneofthemmayoccurinanypatientwithcoronaryheart
disease.Buttheseindicationsoftheunderlyingconditionofthe
heartanditsarterieshavenorelationtofitness.Peoplewith
coronaryheartdiseaseandnosymptoms,thosewithangina
pectorisandheartattacksandthosewhowillexperiencesudden
cardiacdeathmayallbeinfineshapeasfarastheirabilityto
exertthemselvesisconcerned.Furthermore,almostnomatter
whattheirleveloffitness,theymayallenhancetheirfunctional
capacitybyexercise,yettheconditionoftheirheartremainsthe
same.
Thefactthathealthandfitnessaredistinct,thatpeoplewith
severe,evenimminentlyfatalcoronaryheartdiseasecanbevery
fitandthatindividualswithcoronarydiseasecanenhancetheir
functionalcapacitybyexercisewithouttherebyimprovingtheir
healthmaybedifficulttoaccept.Thefactbecomesmore
acceptable,however,withanunderstandingofwhatfitnessis,
andwhatthehearthastodowithit.
Theamountofphysicalworkyoucandoyourfitness
ultimatelydependsontheamountofoxygenthatyourbody
tissuesreceiveandcanuse.Functionalcapacity,infact,is
definedbyphysiologistsintermsofoxygenutilizationor
oxygenconsumption.Themoreoxygenyourbodycanuse,the
moreactivityyoucando;andthemorephysicalworkyou
actuallydo,themoreoxygenyourbodyconsumes.Your
ultimatefitnessorfunctionalcapacity,then,ismeasuredbythe
greatestamountofoxygenyourbodycanusewhenyouare
performingatpeakeffort.
Sincealloftheoxygenyourbodytissuesreceiveiscarriedin

yourbloodstream,andsincethebloodispumpedaroundyour
bodybyyourheart,itseemsintuitivelylogicalthatyour
functionalcapacitymustdependprimarilyuponyourheart.An
increaseinyourcapacityforphysicalworkseemstoimplyan
increaseintheperformanceofyourheart.Asalogical
consequenceofapresumedenhancementofyourheart's
performance,thenotionsofa"strongerheart,""healthierheart"
and"betterheart"seememinentlysensible;certainlythose
notionshavebecomeuncriticallyaccepted.
Yourheartandcardiovascularsystem,however,arenotalways
logical.Whatseemssensibleandappearsreasonableisnot
necessarilyso.Thefactofthematteristhatmuchofwhat
constitutesanimprovementinyourabilitytoperformphysical
workisnotdirectlyrelatedtoyourheart.Althoughcardiac
changesdooccurasfunctionalcapacityincreases,theyarenot
inherently"better"or"healthier."
Sincetheamountofoxygenyourbodycanusedeterminesyour
capacityforphysicalwork,yourbody'sfitnessislimitedbythe
amountofoxygenavailabletoit.This,inturn,dependsuponthe
amountofoxygenintheairyoubreathe,andontheconditionof
yourlungsandyourblood.Oxygenistransferredfromtheairto
yourbloodstreaminsideyourlungs;diseasesofthelungsor
abnormalitiesintheblooditselfcaninhibitthisnormaltransfer
ofoxygenfromtheairintoyourbody.
Assumingtheairyoubreathehasnormalamountsofoxygen
andyouhavenounusuallungorbloodconditionthatinterferes
withoxygenenteringyourbloodstream,theamountofoxygen
yourbodyhasavailabletoitthendependsuponhowmuch
bloodyourheartpumpstoyourcells.Yourheartcanincrease
theamountofblooditpumpsaroundyourbodybyincreasing
the"heartrate"thenumberofheartbeatsperminuteorby
increasingwhatiscalledthe"strokevolume"theamountof
bloodpumpedwitheachheartbeat.Assumingtheheartis

pumpingplentyofbloodaroundyourbody,howmuchoxygen
canbeusedultimatelydependsonthebodycells.Yourbody
cellscanincreasetheamountofoxygentheyusebyextracting
moreoftheavailableoxygenfromthebloodthatcomestothem.
Wheneveryouexerciseorperformphysicalwork,yourbody
normallyrespondsinanumberofdifferentways.Themost
importantofthesechanges,leadingtoincreasedoxygen
availabilitytothebody'scellsinresponsetoexertion,are
increasesinyourheartrateandstrokevolume.Theseincreases
aremainlyduetonervesignalsthatyourbrainsendstoyour
heartasmoreoxygenisneeded.Thecombinedeffectofthe
heartchangesistopumpmorebloodandtherebymakemore
oxygenavailabletothecellsofyourbody.But,additionally,
removalofoxygenfromthebloodstreambyyourbody'smuscle
cellsincreases,sincecellsthatproduceandreleaseenergyat
highrates,likeworkingmusclecells,extractalargeportionof
theoxygenfromtheblood.Allthreeeffectstheincreasesin
heartrate,strokevolumeandoxygenextractioncombineto
allowyoutodomoreactivity.
Ifyouexerciseregularlyatacertainintensityandforacertain
periodoftime,youcanachievewhathasbeencalledthe
"trainingeffect."Thetermreferstoaseriesofphysiologic
changesthatoccurinthebodyasaresultofdoingregular
"aerobic"exercise.(Aerobicreallyjustmeans"oxygenusing,"
andthereforeallhumanactivityisaerobic;appliedtoexercise,
however,aerobicrefersspecificallytoactivityinwhichthe
amountofoxygenusedbythebodyincreasesdirectlyand
predictablywiththeamountofphysicalexertion.)These
physiologicchangesofthetrainingeffectinclude:slowerresting
heartratewhenyou'reinactive;slowerheartrateandlower
bloodpressurewhenyou'reexertingatyourpeaklevel;faster
returntoyournormalrestingheartrateafteryou'vefinished
exercising.

Somehowthenotionmistakenlyarosethatthesephysiologic
changesofthetrainingeffectareautomatically"healthier"or
"better."Butthere'snoevidencethataslowerrestingheartrate
ishealthierthanaheartratesomewhatfaster,orthataquicker
returntorestingheartrateafterexerciseisinherentlybeneficial.
Nobodyhasshownanybiologicaladvantagetoaslower
heartbeat.Ihavepatientsintheireightiesandninetieswhohave
somewhatrapidheartbeatsandhavehadthemsincetheir
childhoods.Ifyouwerebornwithafinitenumberofheartbeats
foryourlifetime,thenaslowerheartratewouldbedesirable,
sinceyouwouldlivelongerbeforeusingupyourallotment.But
thereisnosuchallottednumberofheartbeatsforanybody.
Slowerheartrateandlowerbloodpressureatphysicalexertion
levelslessthanyourmaximumcouldpossiblybeadvantageous.
Thiswouldbesoifyouhadaheartconditionlikeangina
pectoris,andphysicalactivityprovokedchestpainsor
breathlessnessbecausetoolittleoxygenwassuppliedtoyour
heartmusclewhenyouexertedyourself.Withaslowerheart
rateandlowerbloodpressure,yourheartmusclewouldrequire
lessoxygen(heartrateandbloodpressurelargelydetermine
howmuchoxygenyourheartmuscleneeds).Youwould,
therefore,belesslikelytohaveanginaattackswhenyouexerted
yourself,sincepainandbreathlessnessoccurwhentheoxygen
needsoftheheartmuscleexceedtheoxygensupply.By
loweringtheheartrateandbloodpressure,youreducetheneed
ofyourheartmuscleforoxygen,andbringthatneedinto
balancewiththeoxygensupply.But,thinkoftheparadox:in
ordertoachieveslowerheartrateandlowerbloodpressure,you
havetoexerciseregularlyandraiseyourheartrateandblood
pressurewhiledoingit!
Ifareductioninheartrateandbloodpressureisnecessaryfor
youbecauseofaheartconditionorotherreason,thereare
meansotherthanexercisetoachievetheseends.Relatively
simplemedicationsareavailable,and,infact,aresafelyand

regularlyusedbymillionsofpeopleintheUnitedStatesand
aroundtheworld.Thesemedicationsnotonlylowertheheart
rateandthebloodpressurebutalsoare"cardioprotective,"that
is,theyhelptopreventheartattacks.Thisprotectiveeffecthas
beenprovedinpatientswhohavealreadyhadoneheartattack,
andmanycardiologistsbelievetheprotectionmayextendto
thosewhohavenot,althoughnospecificstudiesonthispoint
havebeenmade.So,ifaslowerheartrateandlowerblood
pressurearenecessarygoalsbecauseofheartdisease,itseems
imprudenttoundertakeavigorousexerciseprogramtoachieve
them.
Ofcourse,onecanarguethatmedicationshavesideeffectsand
thatitispreferabletoachievethingsina"natural"wayasif
pushingyourbodytonearexhaustinglimitsandpursuingsome
arbitraryheartrategoalare"natural."It'struethatmedications
havesideeffects.Everymedicinemayhavesomesideeffectin
somepatients.Whatisignoredarethepossiblesideeffectsof
exercisesideeffectsthatmaybemoresevereandmore
dangerousthanthoseduetomedications.
Innormalindividuals,thosewithoutcardiovasculardisease,one
evidentchangeoccurstotheheartwithprolongedphysical
training.Itisthesocalledathlete'sheart,wheretheheart
enlarges,attimesdramatically.Itpumpsmorebloodwitheach
heartbeatandtherearemicroscopicchangesofunknown
significancewithintheheartmusclecells.Whethertheseare
biologicallybeneficialchangesisentirelyunclear;manyofthe
changesresemblethoseseeninheartdisease.Enlargementof
theheart,forexample,isoftenaserioussignofadiseasedheart
compensatingfordifficultiesinpumpingbloodbutinan
athleteitissaidtobeabeneficialadaptationtoincreased
performance.Athletesfrequentlyhaveabnormal
electrocardiograms,manifestingchangesthatinnonathletes
wouldbeconsideredunmistakablesignsofdisease.The
advocatesofvigorousexercisetrainingdismisstheseas

"normal"adaptations.Iamnotatallsure.Althoughtheathlete's
heartmayfunctionsuperiorly,itmaynotbeahealthierheart.
Asforincreasingmaximumoxygenconsumptionwhenyouare
exercisingatyourpeak,thereiscertainlynothingintrinsically
healthieraboutthat.Ifyou'reanathletewhosesportrequires
prolongedexertionandendurance,thenitisnecessary.Ifyour
lifestylerequirestheabilitytoperformmorephysicalwork,then
youmustexercisetoachievethatcapacity.Ihavenoquarrel
withthefactthatexercisetrainingistheonlywaytoincrease
yourphysicalcapacityforwork.WhatIdoseriouslyquestionis
theideathatitishealthier.
Fitnessismeasuredphysiologicallybyoxygenconsumption,
andyourbodymaybeefficientinitsuseofoxygen,soituses
lessforagivenamountofworkperformed.Butthisdoesn't
meanathingtoyourheart,insicknessorinhealth.Peoplewith
evenseverecoronaryheartdiseasecanbe"trained"with
exercise,butitdoesn'talterthefactorseverityoftheircoronary
arterydisease.
Mostoftheimprovementinfunctionalcapacityduetoexercise
isnotevendirectlyrelatedtotheheart.Itisduetoaneffecton
theperipheralmusclecellswherebytheymoreefficiently
extractanduseoxygenfromtheblood.Dr.GeorgeSheehan,the
"guru"ofrunning,hassaid,
"Youmightsuspectfromtheemphasisoncardiopulmonary
fitnessthatthemajoreffectoftrainingisontheheartandlungs.
Guessagain.Exercisedoesnothingforthelungs;thathasbeen
amplyproved....Nordoesitespeciallybenefityourheart.
Running,nomatterwhatyouhavebeentold,primarilytrains
andconditionsthemuscles."(1)
Inpeoplewithheartdiseaseespecially,virtuallyallimproved
fitnessisduetochangesintheabilityoftheperipheralmuscle
cellstoextractanduseoxygenfromthebloodstream.Theexact

mechanismbywhichmusclecellsbecomemoreefficientin
removingoxygenandusingittogenerateandreleaseenergyis
unknown,butitisnotduetoanymeasurablechangeinthe
healthorthefunctionoftheheart.ColumbiaUniversity
cardiologistDr.JonathanMoldoverdeniesthereissuchathing
as"cardiovascularfitness,"becausefitnessisrelatedto
peripheralchanges.(2)
Ifphysicalfitnessinsuredhealthingeneral,thenonlyan
accidentcouldbringdownfitindividuals.Certainlyif
cardiovascularhealthwereeitheraproductorapreconditionof
physicaltraining,thenfitpeoplewouldn'tdieofheartdisease.
Thefactisthatnotonlydoexerciserssuffertheusualillsthat
plagueusall,buttheleadingcauseofexerciserelateddeathsin
welltrainedpeopleiscoronaryheartdisease.
Youcan,ofcourse,befitandhealthy.Yetyoucanbe
physicallyfitandfatallyillwithcoronaryheartdisease,justas
youcanbewonderfullyhealthybutquiteunfitintermsof
exercisecapacity.Finally,youcanbeunfitandunhealthyas
well.Itisthislastcategorythatposesthegreatestproblemboth
tothemedicalprofessionandtowouldbeexercisers.Theout
ofshapepersonwhoalsohasatherosclerosiswillputquitea
strainonaheartalreadypressedforoxygenintheprocessof
becomingfit.Yetpeoplemayundertakeexercisewithout
knowingwhatconditiontheirheartisin,anddoctorsmay
prescribeexercisetothosetheyknowtohaveheartdisease.
Sincethereisnoclearordirectrelationshipbetweencardiac
healthandaerobicfitness,adoctorwouldliketoknowbothhow
fitapersonisandwhatconditionhisheartisinbeforeassuring
himthathecansafelyjogtwomilesaday.Therefore,
physicianshavesoughtforwaystodiagnoseheartdiseasewhen
itispresent,toexcludeitwhenitisabsent,andtoassess
functionalcapacity.Thebasictoolincurrentuseistheexercise
stresstest.

3. What Stress Tests Don't Tell

Eachyeartensofthousandsofnewlyconvertedbelieversare
turnedloosebyphysicianstojointhemillionsofalready
confirmedexerciseenthusiastswhopoundthestreets,fillthe
parksandlinetheroadwaysofourcitiesandcountryside.For
thousandsmore,exerciseisformallyprescribedand"dosages"
establishedaspartofatreatmentregimeninthehopesof
preventingatherosclerosis,reducingsymptomsofangina
pectorisorforestallingaheartattackTheapprovalandthe
prescriptionofexerciserestlargelyonthefoundationofastress
test.
Thebasicconceptunderlyingstresstestingisthatsome
abnormalitiesoftheheartthatarenotapparentwhenyouareat
restmaybecomeevidentduringphysicalwork.Yourheart
worksharderduringactivity,andperformingaphysicaltask
thestressmayprovokeabnormalcardiacresponses.Astress
testthuslooksathowtheheartperforms.Howmuchphysical
workyoucando,ofcourse,dependsultimatelyontheamount
ofoxygenyourbodycanuse.Butoxygenconsumptionis
difficulttomeasure.Heartratethenumberofheartbeatsper
minuteiseasytocountandrecord.Sinceincreasesinheart
rateroughlyparallelincreasesinoxygenconsumptionduring
exercise,yourheartrateisusedasaconvenient,althoughonly
approximate,measureofhowmuchworkyoudoduringthe
stresstest.
Ifyouhaveconsultedaphysicianwithinthelastfewyears,the
chancesaregoodthatastresstestwasrecommendedtoyou.
Perhapstheideaofhavingastresstesthasoccurredtoyoueven
withoutaphysician'ssuggestion,sincesomuchissaidand
writtenaboutit.Muchofwhatyouhearandseeaboutstress
testingis,however,misinformation.Worse,manyofthosewho
performandevaluatethetestapparentlyentertainmistakenand

invalidjudgmentsastoitsvalue.
Stresstestsaredesignedmainlytodotwothings:detector
confirmthepresenceorabsenceofheartdisease,andestablisha
safelevelofexerciseforyou.Stresstestingdoesneitherofthese
reliably.Itis,infact,ofverylimitedvalueandmayproduce
misleadinginformation,sometimeswithdangerous
consequences.
Thevariousmethodsofstresstestingcanbedividedintotwo
generalcategories:singlestageandmultistage.Inasinglestage
test,yourlevelofphysicalworkorstressiskeptconstant
throughouttheexercise.Thebestknownsinglestagetestisthe
originalMasterTwoStepTest,whichinvolveswalkingupand
downtwospeciallyconstructedstepstoincreaseyouroxygen
consumptionandyourheartrate.
Thenumberoftimesyouhavetogoupanddownthestepsina
MasterTwoStepTestisdeterminedbyyourageandweight.
Theolderyouare,andtheheavier,thefewer"trips"overthe
stepsarerequired.InasingleMasterTwoStepTest,youmake
theprescribednumberoftripsinoneandonehalfminutes;in
thedoubleversion,whichispreferredbysomebecauseitoffers
agreatertotalamountofexercise,youmaketwicethenumber
oftripsanddoitintwicethelengthoftime.Afurther
refinementistheaugmentedDoubleMasterTwoStepTest,in
whichyoumakeanadditionalnumberoftripsupanddownthe
stepsinthesamethreeminutestoincreasetheworkloadofyour
heart.
Alessknown,butstilloccasionallyused,singlestagetestisthe
isometrichandgriptest.Here,sustainedsqueezingwithyour
handsprovokesonlysomeincreaseinheartratebutasignificant
increaseinbloodpressure.Risesinbloodpressuredon't
correlateaswellwithoxygenconsumptionasincreasesinheart
ratedo,sothistestistheleastvaluableone.Sinceasuddenrise

inbloodpressuremayalsohavedireconsequencesforsome
cardiacpatients,thistestisgenerallyavoidedifyouare
suspectedofhavingcoronarydisease.
Amultistagetestreliesonsuccessivelyincreasinglevelsof
activity.Youexercisefirstatalowintensityofeffort,andthen
progressivelyathigherlevelsofphysicaleffort.Youstayat
eachlevelofactivitylongenough(usuallythreeminutes)for
yourbodytoachieveanequilibriumorsteadyresponsetothat
levelofactivity.Multistagetestingcanbecontinuous,going
fromonelevelofefforttothenextwithoutstopping,or
intermittent,withaperiodofrestafterequilibriumateachlevel
ofactivityisachieved.Mostmultistagetestingtodayis
continuous.
Multistagestresstestingisusuallydoneonatreadmillora
stationaryexercisebicycle.Thedifferencesinresultsbetween
thetwokindsofapparatusarenotgreat,anddoctorsoften
decidewhichtousemostlyonthebasisofhowmuchtheywant
tospendandhowmuchspacetheyhaveavailable.Buttreadmill
testingdoeshavetheadvantagesofusingafamiliarmodeof
exercisenamely,walkingandofbringingintousethelarge
musclegroupsofthehipandpelvicareas.Thetreadmillalso
automaticallyregulatestheworklevelaslongasyoucontinue
walkingonit.
Intreadmilltestingyoustepuponandthenwalkintimewitha
movingbelt.Thelevelofexerciseintensityisvariedbythe
speedandtheslopeofthetreadmill.Testsusuallybeginwitha
treadmillspeedof1.7milesperhourandanupwardslopeof10
percent.Successivelevelsofexerciseinvolvefasterspeedand
steeperslopeuptoamaximumof6milesperhouranda22
percentgrade.Usually,onlyenduranceathletescanperformat
thismaximumlevel.Regularlyactivehealthymencanusually
completethreeminutesoftreadmillexerciseat4.2milesper
houranda16percentgrade.Peoplewhoarelessfithave,by

definition,lesscapacityforphysicalwork,andtheirmaximum
treadmillperformanceisatlowerspeedsandgrades.
Inbicycletestingyousituponastationarybicycle.Theintensity
oftheexerciseisvariedbyvaryingtheresistancetopedaling,
sincethespeedofpedalingiskeptconstant.Unlikethe
treadmill,whereyouareforcedtocarryyourownweightand
thetotalamountofoxygenyouuseforagivenamountofeffort
willthereforevarywithyourbodyweight,youaresittingonthe
bicycle,sothetotaloxygenrequirementforagivenamountof
pedalingisindependentofyourbodyweight.Butmanypeople
arenotaccustomedtovigorousbicycleriding;theirthighand
calfmusclesbegintocrampupor"turntojelly"beforethey
havehitthepeakefforttheymightbecapableofinsomeother
formofexercise.
Theendpointofamultistagetestmayvary.Someproponentsof
stresstestingadvocatewhatiscalled"maximal"testing,which
meansyouexercisetothatpointwherefurtherincreasein
physicalworkdoesnotcausefurtherincreaseinhowmuch
oxygenyouuseorhowfastyourheartbeats.Sinceheartrateis
whatisusuallymeasured,maximalexercisefoiyouisthatlevel
ofeffortbeyondwhichyourheartratedoesnotriseanymore.
Atthismaximallevel,normalpeopleusuallyfeelexhausted,
andoftennauseatedanddizzyaswell.
Moreconservativetesterschoosea"submaximal"endpointfor
stresstesting.Inasubmaximaltest,anarbitraryendpointis
chosen,usuallyaheartrateequalto85percentoftheexpected
maximumheartrateforyourage.Sincetheexpectedmaximum
attainableheartratedecreasesasyougetolder,aconvenient
formulaforpredictingaveragemaximumheartrateis220minus
age.Thus,ifyouareanormal40yearoldmalehavingasub
maximalexercisetest,yourpredictedmaximumattainableheart
ratewouldbe220minus40,whichequals180;and85percent
ofthatis153,whichrepresentsthearbitraryendpointofthe

test.
Ifyouareapatientwithcardiacsymptoms,yourexercisetestis
usuallysymptomlimited.Thatis,thetestisstoppedwhatever
thelevelofexerciseyouachievewhenyoureportthatyouare
experiencingsymptomsofyourcondition,suchaspain,
dizzinessorbreathlessness.Somepatientsmayshowsignsof
abnormalcardiacfunction,suchaspallororunsteadiness,that
canbenotedbytheexaminerevenbeforeanysymptomsare
felt.Thetestisthenstoppedatthatpoint,evenifthepatientstill
feelscomfortable.
Althoughyourperformanceofthephysicaleffortisthebasisof
thetest,andhowyoulookandfeelduringthetestisimportant,
theexaminerreliesmoreonobservingandrecordingyour
physiologicresponsestostress.Manykindsofresponsescanbe
measured,includingtherateofyourheart,itspatternof
electricalactivity,yourbloodpressureandoxygenconsumption.
Whereasalloftheseresponsesaremeasuredinafewtechnically
sophisticatedtestingcenters,inmosttestingsituationsonlythe
electricalresponsesofyourheart(whichautomaticallygivethe
heartrate)andperhapsyourbloodpressurearerecorded.
Theelectricalactivityofyourheartisrevealedinyour
electrocardiogram,arecordingoftheelectricsignalsthattravel
throughtheheart.Theheartcannotbeatunlesstheheartmuscle
iselectricallystimulated.Heartbeatisnormallyregulatedby
electricsignals,generatedwithintheheartitself,thattravel
throughthemusclescausingrhythmic,coordinatedpumping
contractions.Theelectrocardiogramshowsalltheelectric
signals,soitisveryeasytocountthenumber.ofthemand
therebyknowtheheartrate.Analyzingmoresubtleaspectsof
patternandcontourofthesignalsastheyappearonthe
electrocardiogramismuchtrickier.Tobehonest,wedon'teven
knowallthereasonswhyanormalelectrocardiogramtaken
whileapersonisrestinglooksthewayitdoes,andwecertainly

don'thavealltheanswersastowhycertainelectricalchangesin
theheartoccurduringexerciseorstress.Nevertheless,through
experiencewehavelearnedtorecognizemanyabnormalities
andtojudgewithfairaccuracywhatconditionstheymight
indicate.
Howdetailedanelectrocardiogramisdependsonthe
complexityoftheequipmentused.Inallrecordings,electric
signalsfromyourheartaredetectedbysensingdevicescalled
electrodesthatareplacedonvariouspartsofyourbody.A
simpleelectrocardiogramsystem,usingveryfewrecording
electrodes,maybeusedonthegenerallyvalidassumptionthat
mostabnormalitieswillbedetected.Moreelaboratesystems,
usingmanymoreelectrodes,maybeemployed,however,since
itisknownthatcertainabnormalresponsesmaybemissedby
thesimplersystem.Whethertheseabnormalitiesdetectedonly
bythemoreelaboraterecordingsystemshaveanyclinical
significanceisstilldebatable.
Sometestersruntheelectrocardiogramcontinuouslyduring
exercise,whileothersrecordonlyabriefperiodattheendof
eachstageofamultistagetest.InthesinglestageMaster
TwoStepTest,theelectrocardiogramisnotmadeuntil
immediatelyafteryoucompletethefullexercise.Although
moreinformationmaybeobtainedfromrecordingduring,as
wellasafter,exercisethe"extrainformation"maybe
misleadingandleadtoerrorsininterpretation.The
electrocardiogramisalsousuallymadeduringtherestperiod
afterexercisebecause,asyourcirculatorysystemcontinuesto
readjust,abnormalitiesoccasionallybecomeevidentthatwere
notdetectedduringtheactualexerciseorinthefirstminutesof
resting.Someofthedeathsthatoccurasaresultofstresstesting
anddeathsdooccurhappenintheperiodfollowingthe
actualexercise.
Eventakingyourbloodpressure,sosimpleandstandardizeda

procedurewhenyou'resittingstill,becomesacomplicated
manoeuvreduringstresstesting.Bloodpressureistheactual
pressureoftheblood,measuredinmillimetersofmercury,
withinthearterialsystemofthebody.Withyoubobbingupand
down,scramblingtokeeppacewithatreadmillorfuriously
pedalingabicyclegoingnowhere,itisveryhardforsomeoneto
measureyourbloodpressureaccuratelywiththestandardcuff
aroundyourarm.Sometesters,therefore,ignoreyourblood
pressurealtogetherorrecorditonlyinfrequentlyduringthetest.
Yet,accuratelyrecordedbloodpressureresponsestoexercise
maybeveryhelpfulindiagnosingabnormalitiesoftheheart.In
somecenterswherehighlysophisticatedphysiologicstudiesare
performed,aneedleorcatheterconnectedtoasensitivepressure
gaugemaybeinserteddirectlyintooneofyourarteriesfor
directmeasurementofyourbloodpressureasyouexercise.
Theresultsofatestusinganelaborateelectrocardiogramsystem
maynotbereliablycomparedwithresultsfromasimplerone,
justasdifferencesinthetimingandthemethodofmeasuring
eitherelectricalorpressureresponsesgivetheexaminer
differentdatafromwhichtomakejudgments.Lookingatone
setofmeasurements,adoctormightfeelthatapatienthada
perfectlynormalheart.Usinganothersetofmeasurements,he
mightbejustascertainthesameheartwasabnormal.These
differencesintestingprocedures,techniquesandequipment
affecttheexaminer'sconclusionsabouttheactualstateofan
individual'sheart.
Inspiteofthesevariationsindatathatcanleadtodiffering
interpretations,examinersassumethatstresstestingdoes
accomplishitsbasicaims:todiagnoseorexcludeheartdisease
andtomeasuretheperformanceyouarecapableof.Mostpeople
"pass"theirstresstest.Theircardiachealthiscertified,theyare
toldwhat"shape"they'reinandtheygoofftobuytheirnew
athleticgear.Whenthebillarrives,theypayitwillingly.It's
worththemoneytoknowthey'rewellandthatit'ssafeto

exercise.Buttheydon'tknowthat,andneitherdoestheirdoctor.
Justasimportant,whenpeoplewho"fail"theirstresstestare
toldtheyhaveheartdisease,thatconclusionmaybeequally
uncertain.
Themostcommonpurposeofstresstestingistofindout
whetheryoudoordon'thavecoronaryheartdisease.That'swhat
theCommitteeonExerciseoftheAmericanHeartAssociation
says,(1)andthat'swhatmostdoctorsthinktheyaredoingwhen
theysuggestyoutakeastresstest.Manyofyouconsidering
havingastresstestprobablyhavethisobjectiveinmind,too
todetectcoronaryheartdiseaseifitispresent.Impliedinthisis
thenotionthatifthestresstestdoesnotrevealcoronaryheart
disease,thenyoucanconcludewithconfidencethatyouarefree
fromit.
Thetroubleisthatthisconclusioniswrong.Astresstestdoesn't
necessarilydetectcoronaryheartdisease,andanormaltestis
notfirmevidenceoftheabsenceofcoronarydisease.
Astresstestshowshowwellyoucanperformwhenpushedto
workhardduringexercise.Itisatestoffunctionor
performance.Butcoronaryheartdiseaseisstructural,a
narrowingofthecoronaryarteriesthatcarryoxygenladenblood
totheheartmuscle.Itisnotadiseaseofperformance,andmay
notinterferewithfunctionatall.Youcanhavenice,clean
coronaryarteriesbutaheartthatdoesn'tperformwellduring
hardwork.Youcanhaveaheartthatcarriesyouthrougha
stresstestwithflyingcoloursbutcoronaryarteriesthatare
alreadyconstrictedwithfattydeposits.
Evenifyourelectrocardiogramandothermeasuresshow
somethingunusualinthewayyoufunctionduringastresstest,
coronaryheartdiseaseisonlyoneofmanypossiblereasons,
someofwhichareinnocuousanddon'tindicateanythingone
wayoranotherabouteitherthepresenceofdiseaseorhow

muchexerciseyou'recapableof.Infact,abnormalitiesineven
restingelectrocardiogramsarenotatalluncommon,andare
oftenrelatedtoharmlessandnoncoronaryconditions.Many
physicianswillnotdoastresstestifyourresting
electrocardiogramrevealssuchchanges,becauseitissolikely
thatthestresstestwillappeartobeabnormal.
Evenifyourrestingelectrocardiogramlooksperfectlynormal,
therearemanyconditionsthatcanmakeyourstress
electrocardiogramlookabnormal.Abnormalitiesofheartvalves,
forexample,maybeassociatedwithabnormalexercisetests.If
youtakecertainmedicines,foranotherexample,thestress
electrocardiogrammaybeabnormal.Anemia,withitslowred
bloodcellcount,canproduceanabnormalstresstest.Andhigh
bloodpressure,too,maybethecauseofabnormal
electrocardiogramresponses.Yet,withtheseconditions,
exercisewouldnotnecessarilybelimitedorproscribedtothe
sameextentitwouldbeifcoronarydiseasewereresponsiblefor
theabnormalelectrocardiogram.
Sometimes,ifyouhavesimplyeatenwithinanhourortwoof
thestresstest,itwilllookabnormal.Thiswasthecasewitha
prominentbusinessexecutivewhoisnowchairmanoftheboard
ofoneofthemajorcorporationsinthecountry.Hisstresstest,
reviewedattherequestofthecompanyunderwritingthe
insuranceaspectsofhispotentialappointment,wasabnormal.
Whenthetestwasrepeatedafterhehadhadnofoodforseveral
hours,itwasperfectlynormal,andamajorpersonaland
corporateproblemevaporated.
Theothersideofthecointheinabilityofanormalexercise
testtoexcludethepresenceofcoronaryheartdiseaseisabout
ascommon.Youcanhavenarrowingofyourcoronaryarteries,
evenofseveredegree,andrespondnormallytoastresstest.
Sometimesthetechniqueofrecordingtheexercise

electrocardiogramisinadequate,orthetesthasbeenstoppedtoo
soon,beforeabnormalresponseshaveachancetoemerge,but
therearemanyotherreasons.Anoldheartattackmightprevent
theelectrocardiogramsignsofcurrentcoronarytroublefrom
showingup.Also,therestingelectrocardiogrampatternsof
somepeoplecaninhibitabnormalresponsestostress.Finally,
justassomemedicinescanproduceabnormalstress
electrocardiogramsintheabsenceofcoronarydisease,socan
certainmedicinespreventanabnormalstresselectrocardiogram
inthepresenceofcoronaryheartdisease.
Anexercisestresstestcannotachieveitsmajorgoalof
accuratelydetectingcoronaryarterydiseaseorrulingitoutin
anygivenindividual.Althoughthedirectorofawellknown
exercisetestingcentersuggeststhatitgives"anindirectimage
oftheextentthatatherosclerosishasnarrowedtheindividual
coronaryvessels,"exercisetestingreallygivesonlyverylimited
andnonspecificinformationaboutsomecardiovascular
responsestooneformofstress.Stresstestingisdefinitelyan
imperfectwaytodetectorexcludecoronarydisease,but
proponentsarguethatitmightneverthelessbereliableenough.
Whatdegreeofreliabilitycanyouasanindividualputonthe
resultofyourtest?
Onewaytocheckatest'sreliabilityistoseehowsensitiveitis
howoftenitreallypicksupcoronaryheartdisease.A
perfectlysensitivetestwouldpickupeverycaseofheart
disease,andwouldbe100percentsensitive.Ifthetestpicksup
90abnormalresultsoutof100peoplewithcoronarydiseasethe
sensitivityis90percent.Asecondwaytocheckatest's
reliabilityistoseehowspecificitishowoftenanormalresult
reallyindicatesthatthepersonisfreeofcoronarydisease.With
aperfectlyspecifictest,everyonewhoshowedanormalresult
wouldhavenormalcoronaryarteries,andthetestwouldbe100
percentspecific.If100peopledonothavecoronarydisease,and
90ofthemhaveanormaltest,thespecificityofthetestis90

percent.
Anabnormaltestresultiscalleda"positive"result,meaning
somethinghasbeenfound.Anormaltestresultiscalled
"negative"nothinghasbeenfound.Peoplewhohavecoronary
diseasebuthaveanegativetestaresaidtohavea"false
negative"test.Peoplewhodonothavecoronarydiseasebut
haveapositivetestaresaidtohavea"falsepositive"test.If100
peoplehavecoronarydiseaseand90ofthemhaveapositiveor
abnormaltest,and10ofthemhaveanegativeornormaltest,
thenthesensitivityis90percent,andthefalsenegativerateis
10percent.Likewise,if100peopledonothavecoronary
diseaseand90ofthemhaveanegativeornormaltest,and10of
themhaveapositiveorabnormaltest,thespecificityis90
percent,andthefalsepositiverateis10percent.
Manystudieshavebeendonetodeterminethesensitivity,the
specificity,thefalsepositiveandfalsenegativeratesinexercise
stresstesting.Sensitivityhasbeenestimatedaslowasabout40
percentandashighasover90percent;usuallyit'sconsideredto
beabout75percent.Inotherwords,thetestdoespickup75
percentofpeoplewhodohavecoronarydisease.Butthe
remaining25percentofthepeoplewithcoronarydiseaseshow
nothingunusualintheirstresstests,sothefalsenegativerateis
25percent.Instudiesthathavereportedtheleastsensitivity,the
falsenegativerateis60percent,meaningthetestmisses60out
ofevery100peoplewhodohavecoronarydisease.
Figuresforspecificityofstresstestinghavealsovariedwidely,
fromaslowas65percenttoashighas95percent.Ifwe'reto
believethelowfigure,65percentofnormalpeopleshowa
normalelectrocardiogramintheirstresstest,but35percentof
thesehealthymenandwomen,withoutcoronarydisease,havea
falselyabnormalorfalsepositivetest.Reportedfiguresforfalse
positiveresultsabnormaltestsfornormalpeoplerangefrom
5percenttoashighas35percent.Andincertainspecialnon

coronarysubgroups,suchaswomenwithaminorheartvalve
abnormalityandnormalcoronaryarteries,positivetestshave
beenrecordedforasmanyas64percent.
Thistremendousvariabilityinthesetestresultsmust,byitself,
suggestsomerealproblems,notonlywiththeactualreliability
ofstresstestingprocedures,butalsoevenwithhowtofigureout
reliablyhowreliabletheyare.Worse,thisvariabilityofresults
underestimatestheproblemofreliabilityasfarasyouasan
individualareconcerned.Moststudiesofstresstestinghave
involvedpeopleknowntohave,orstronglysuspectedofhaving,
coronaryheartdisease.Ifyoutestagroupofpeoplemostof
whomprobablydohavethediseaseyou'retestingfor,then
obviouslymostofthepositivetestswillbetruepositives,since
thepeopledo,infact,havethedisease.Butifyoutestagroup
ofpeoplemostofwhomdonothavethedisease,thenmanyof
thepositivetestswillbefalsepositives.
Ifyouasanindividualknowthatyouhavecoronarydisease,or
stronglysuspectit,thenastresstestaddslittleornothingto
yourknowledge;apositivetestwouldbeexpected,anda
negativetestwouldbehighlysuspectofbeingafalsenegative.
Ifyouhavenoreasontosuspectyouhavecoronarydisease,then
thereliabilityofastresstestisparticularlypoor,sinceapositive
testwouldlikelybeafalsepositive;andanegativetest,
althoughexpected,couldnotexcludethepossibilityofcoronary
disease.
AstudyfromtheNationalInstitutesofHealthisparticularly
relevantinthisregard.(2)Among39subjectswhohadno
symptomsofheartdiseasebuthadabnormalstresstests,only36
percenthadsignificantcoronarydiseasewhentheirarterieswere
examinedbyspecialxraysafterdyeinjectionsdirectlyintothe
coronarycirculation.Theresultsin64percentoftheirpositive
orabnormalstresstestsweresimplywrongforthediagnosisof
significantcoronaryarterydisease.Asimilarstudybythe

UnitedStatesAirForcefound75percentfalsepositivestress
testsinpeoplewithoutsymptomswhoneverthelessunderwent
exercisetesting.(3)
Stresstestinginwomenisespeciallymisleading,forreasons
thatarenottheleastbitclear.Insomestudies,morethanhalf
thepositivestresstestsforcoronarydiseaseinwomenarefalse
positive,indicatingdiseasewherenoneexists.Womenmightas
welltossacointoseewhetherornottheyhavecoronarydisease
asrelyontheresultsofatraditionalstresstest.
Anothermeasureofatest'sreliabilityisitsreproducibility
howoftenresultscomeoutthesamewhenthetestisrepeated.
Toconsideratestareliableindicatorofanything,youshould
expectthatrepeatingthetestunderthesameconditionswillgive
resultsthatareverysimilar,ifnotidentical,eachtime.Imagine
anIQtestinwhichyougotascoreof80onedayand150the
next.Sinceintelligencedoesn'tvarymuchfromdaytodayand
neitherdoestheconditionofarteriestestresultsthatfluctuate
thatwayhavenomeaning.Ameasureofsomethingmustbe
reproducible,orelseitsvalidityasastandardormeasureis
compromised.
Whenthequestionofreproducibilityofstresstestinghasbeen
addressed,theresultsaredismaying.
Analyzingtheoccurrenceofirregularitiesoftheheartrhythm
duringexercisetestingshowsthatreproducibilityintwo
consecutivetestsinthesameindividualisaboutequalto
reproducibilitybychancealone.(4)Ifyoutestthesamegroupof
peoplerepeatedly,differentmembersofthegroupwillhave
arrhythmiasoneachtest.Testsdoneascloseas45minutesapart
andthosedonemonthsandyearsapartshowthesamelackof
reproducibility.(5)
Perhapsthemosttellingreportwasdeliveredatthescientific
sessionsoftheAmericanCollegeofCardiologyin1977.(6)The

purposeofthestudywastoassessthereproducibilityofthe
mostabnormalstresstests,theteststhatsuggestedthemost
severedegreeofcoronarydisease.Of34subjectswhohadat
leastoneseverelyabnormaltest,only14hadreproducibly
abnormalstresstests,whileforthe20otherpeopletheseverely
abnormalresponsecouldnotbereproduced.Andin11ofthese
20whodidnothavereproducibletests,atleastoneoftherepeat
testswasactuallynormal.Thus,only41percentofmarkedly
abnormalstresstestswerereproducible,and59percentwere
not.
Muchasanydoctorandthatincludesmewouldappreciatea
foolproofwaytocheckeasilyforcoronarydisease,stresstests
arenotsensitiveenough,specificenoughorreproducible
enoughforanyonetobesurethey'retellingyouanythingatall.
Atmost,astresstestmighthavesomevalueinconfirminga
diagnosisalreadyarrivedatbytheconventionalmeansof
carefullytakingapatient'smedicalhistory.
Thebestanalysisofwhetherastresstestprovidesusable
additionalinformationforyouoryourphysiciancomesfrom
VictorFroelicher,formerlyoftheUnitedStatesAirForce
SchoolofAerospaceMedicineandnowwiththeUniversityof
California,SanDiego.(7)Dr.Froelichersummarizedseveral
previousstudiesoftheaccuracyofdiagnosingcoronaryheart
diseasejustfromthepatient'shistorythesymptomsthepatient
relatedtohisphysician.Diagnosisofthepresenceofcoronary
diseasewasaccurate90percentofthetimefromsymptoms
alone.Inpatientswithnosymptomslikethoseofcoronary
disease,thediagnosisofabsenceofcoronarydiseasewas
correctin95percentofthecases,whilein5percenttherewas
latentorhiddencoronarydisease.
Dr.Froelicherthencalculated,basedonaveragesensitivity,
specificityandreliabilityfigures,howmuchmorecertainty
couldbeachievedifastresstestweredone.Heconcludedthata

positiveorabnormalstresstestforapatientalreadythoughtto
havecoronarydiseasethroughsymptomsaloneraisedthe
probabilityofthediagnosisbeingcorrectfrom90percentto98
percent.Anegativeornormalstresstestinapatientthoughtto
havecoronarydiseaseloweredtheprobabilityofthediagnosis
beingcorrectfrom90percentto75percent.
Inpatientswithnosymptomsatall,apositiveorabnormal
stresstestraisedtheprobabilityofhiddencoronarydiseasefrom
5percentto27percent,whileanegativeornormalstresstest
reducedtheprobabilityofcoronarydiseasefrom5percentto2
percent.
Atfirstglance,thechangesinprobabilityofhavingcoronary
diseasebasedonresultsofstresstestingmightlooksignificant
and,toanepidemiologistconcernedwithhugegroupsofpeople,
theyprobablyare.Butthinkaboutyourselfasanindividual.
Sincetherearesomanyfalsepositiveandfalsenegativetests,
noindividualcantellifhisorherowntestisatruepositiveor
truenegativeorfalsepositiveorfalsenegative.
Ifyouhaveahistorythatindicatescoronaryheartdiseaseyou
alreadyknowtheprobabilityofyourreallyhavingcoronary
diseaseis90percent.Apositivestresstestthatraisesthe
probabilityto98percentdoesn'treallychangeanything.Anda
negativestresstestonlymeansthatthelikelihoodofreally
havingcoronarydiseaseissomewhatless,butitisstill75
percent.Ineithercase,you'dprobablyplayitsafeandconduct
yourlifeontheassumptionthatyou'relikelytohavecoronary
disease.
Bythesametoken,ifyouhavenohistoryatallindicating
coronarydisease,andtheprobabilityofreallynothaving
coronarydiseaseisabout95percent,anabnormalstresstest
onlymeanstheprobabilityofnothavingcoronarydiseaseis
somewhatreduced,butitisstill75percent.Inotherwords,the

chancesarestillthreeoutoffourthatyou'requitewelland
needn'tworryabouthavingcoronarydisease,becausethetestis
likelytohavebeenafalsepositive.
Onthebasisofyourmedicalhistoryalone,anaccurateenough
estimateofthelikelihoodthatyouhavecoronarydiseasecanbe
made.Astresstestdoesnotoffersignificantadditional
informationitmayofferonlyadditionalconfusionandis
thereforequiteunnecessary.
Butletusassumeyouundergoastresstest.Apositiveor
abnormaltestisobviouslyofgreaterconcernthananegativeor
normalone.So,let'sassumetheresultsareabnormal.
Youarenowfacedwiththequestionofwhethertheabnormal
testisatruepositiveorafalsepositiveone.
Youhaveafewoptionsinthiscircumstance,butnonearevery
satisfactory.First,youmaydecidetoignorethetestresultand
relyontheinformationyouhadaboutyourselfbeforethetest.If
thisisyourchoice,whydidyouspendyourtimeandmoneyto
havethetestinthefirstplace?Andyoumaybeleft,asmany
peopleare,withanaggingsenseofanxietyabouttheunderlying
conditionofyourheart.
Asecondchoiceistohavearepeatstresstest.Whoever
conductedyourfirsttestwouldprobablywillinglydoanother.
Afterall,it'syourtimeandyourmoney.Butreproducibilityis
sopoorthatyou'llbestuckwithessentiallythesameproblem
aftertherepeattest.Iftherepeatispositive,isitatruepositive
orafalsepositive?Ifitisnegativethistime,whichtestwas
correct,thefirstorthesecond?Nomatterhowmanytestsyou
undergo,theirreliabilityisquestionable.
Furtherchoicesinfollowingupabnormalstresstestsare
radionuclidescanningandcoronaryangiography.Thefirst
involvesinjectingradioactivematerialintothebloodstreamand

followingitscoursethroughtheheartorcoronarycirculation.
Accuracyofsomeformsofscanningisnotmuchbetterthanthat
ofregularstresstesting.Newerscanningtechniquesaremore
accuratebutthecostmaybeover$500.Angiographyusually
requireshospitalization,becausetubesareinserteddirectlyinto
theheartandcoronaryarteries.Deathandseriousnonfatal
complicationsoccurinasmallpercentageofpatients.
Besidesthedetectionorexclusionofcoronaryheartdisease
whichitfailstoachievereliablytheothermajoraimof
exercisetestingistofindyourexercisecapacityandwhatlevel
ofexerciseissafeforyou.TheCommitteeonExerciseofthe
AmericanHeartAssociationadvisesthat"exerciseintensitythat
isbothsafeandeffectivemustbebasedontheindividual's
exercisetoleranceorcapacity...ameasurementoraccurate
estimateofindividualtolerance...isanextremelyusefulaidto
choosingtheproperintensityatthebeginningofanexercise
program."Thecommitteeaddsthat"exerciseintensitymustbe
regulatedperiodicallyduringthesucceedingstages"ofan
exerciseprogram.(8)
Intheirexercisehandbookforphysicians,theHeartAssociation
alsosaysthat"individualswhocompletetestingwithout
exhibitingabnormalECGelectrocardiogramresponsesorother
evidenceofovertorsubclinicalheartdiseasecanbemedically
authorizedtotakepartinunsupervisedexerciseofanintensity
thatdoesnotexceedthatachievedduringtheclearancetest."In
otherwords,accordingtothis,ifyouoncecompleteamaximal
stresstesttothelevelofexercisewhereyourheartrateand
oxygenusagecannotincreasefurtherdespitemoreexercise,and
youdon'tshowabnormalresponses,thenyoucanfeelsafein
pushingyourselftothatlevelregularly.Ifyourtestisasub
maximalone,say,to85percentofyouragepredictedmaximum
heartrate,thenthislevelofexercisemayberegularlyperformed
withimpunity.

Thisisasplendididealtheaccurateestimationofyour
individualtoleranceforstress,andtheperiodicadjustmentof
youractivitytoyourchangingcapacity.Unfortunately,itisan
elusiveone.Ifullysubscribetotheideal,butIdisputethe
CommitteeonExercisewhenitimpliesthateventhemost
sophisticated,monitored,multistageexercisetestingcanachieve
it.
Ifyouacceptthatstresstestinggivesanaccurateestimateof
yourtoleranceorcapacityforphysicalexercise,you'reassuming
thatyourexercisecapacityisfixedandstable.Butthatisn'tso.
Therearelotsofthingsthatcanchangeyourresponsestothe
sameamountofphysicalstress.Someofthesethingsareunder
yourdirectcontrol:smoking,eating,drinking.Otherthings,
perhapsbeyondyourcontrol,areequallyimportant:
temperature,humidity,airquality,worry,anger,depression.All
ofthesecansignificantlyaffectyourcardiovascularresponses
andyourgeneralbodyreactionstorunning,cycling,aerobic
dancingwhateverkindofvigorousexerciseyouliketodo.
It'snaivetoassumethatyou'llalwaysrespondtoexercisethe
samewayyoudidinthecontrolledenvironmentofyourstress
test.Youcan'trunin90heatthewayyoucaninanair
conditionedoffice.Youcan'tplaysquashaswellifyou'vejust
polishedoffapoundoflasagna.Andcigaretteshavegottoslow
youdownonthetenniscourt.
Thevoguetodayisforphysiciansto''prescribe''exercise,
especiallyforcardiacpatients,muchastheyprescribe
medications,withspecific"dosages"basedonstresstest
performance.Thislendsanunwarrantedairofscientific
precisiontostresstestingandaddstothecredibilityofthe
erroneousideathatexerciseismedicallybeneficial.Butit
doesn'talterthefactthatyourcardiacandotherresponsestoa
specificamountofphysicalactivityvarywithcircumstances.
Theseresponsesmaybeentirelyanddangerouslyunpredictable.

Atragictruestoryillustratesthepoint.Atwentysevenyearold
manwhoexercisedregularlyandrepeatedlyunderwentmaximal
stresstestswithnormalresultssufferedcardiacarrestrunning
onatrackwherehehadrunoftenforyears.Heneverexceeded
thelevelofexercisethatheeasilyachievedinstresstesting.We
learnedlaterthathehadhadseveraldrinksthenightbeforeand
hadsleptpoorlyfollowinganargumentwithhisestrangedwife.
Hisresponsetoexerciseonthatfatefuldaywasnotpredictedor
evensuspectedbyanytesthehadeverhad.Nobodyevertested
himunderhis"reallife"conditions,norisitpossibletodoso.
Actually,stresstestingitselfcarriesrisks.You'llnotethatyou're
askedtosignareleaseformbeforeatest,indicationenoughof
atleastsomepotentialdanger.Thelargeststudyofrisks
associatedwithstresstestingintheUnitedStatesappearedin
theJournaloftheAmericanMedicalAssociationin1971,and
indicated1deathper10,000testsinasurveyof170,000tests
performedatvariouscentersaroundthecountry.(9)When
seriousnonfatalcomplicationswereincluded,theincidence
roseto2.5morbideventsper10,000tests.Alargerandmore
recentstudyfromWestGermanyreported1complicationin
every7,500exercisestresstests.(10)Usingthe1in7,500
figures,ifjusttheestimated30millionjoggersintheUnited
Stateseachhad1stresstestyearly,wecouldanticipate4,000
suchdangerousincidents.AmorerecentAmericanstudy
covering1,375centersshowed8.86complicationsper10,000
tests;(11)oneoftheauthorsofthatstudyreported3deathsinhis
ownseriesof10,000tests.(12)
Inalllikelihood,thefiguresarebutthetipoftheicebergand
underestimatethedangersbecausemanyuntowardeventsand
complicationsarenotpubliclyreported.Also,manystresstests
areprobablyperformedwherepreparationandsupervisionare
notoptimal,andstatisticsfromsuchtestingsitesarelikelytobe
worsebuttogounreported.Moretragic,asignificantnumberof
thereporteddeathsandlifethreateningcomplicationsoccurto

peoplewhosecoronaryarteriesaresubsequentlyshowntobe
normal.
Ifyoustillassumethatstresstestinggivesanaccurateestimate
ofhowhardyoucansafelyexercise,thenit'sonlylogicalthat
youbewillingtospendyourtimeandmoney,andtaketherisk,
ofperiodicallyupdatingyourstresstest.Exercisecapacitycan
diminishaswellasincreaseduetoavarietyofcauses,including
illnessandinactivity.Ittakesjustashorttimeafewdaystoa
fewweeksatmosttolosemostoralloftheconditioning
benefitsofphysicaltraining,andyoushouldbewillingtobe
retestedafteranysignificantinterruptionofyourexercise
routineandperiodicallyduringanyexerciseprogramat$150
ormoreashot.
Ofcourse,fewpeopleundergoregularlyrepeatedstresstesting;
whyshouldtheywhentheyhearfromallsidesthatexercise
itselfwillpreventtheverydiseasethatthetestissupposedto
detect?Armedwithassurancethattheydonothavecoronary
arterydisease,mostpatientsleavetheordealoftheirfirststress
testtoembracewholeheartedlywhattheybelievetobethe
protectionofexercise.

4. The Case Against Longevity

Longevityisthemostcompellingofthepromisedprotectionsof
exercise.Millionsoftoday'sexerciseenthusiasts,seducedinto
thelatestwarmupgear,designerlabelsstickingtotheir
sweatingbodies,run,dance,stretchandstraininthehopeand
expectationoflivinglongerlives.Butdespitethewidespread
notionthatphysicalexercisecanaddyearstoyourlife,thereis
noreliableevidencetoproveit.
Biologicalagingisafactoflife.Althoughsomeresearchers

concludethatwehaveabiologicalpotentialofupto110or120
years,livingthatlongissorarethatmostscientistssettlefora
biologicallimitofabout80years,barringextraordinarynewand
fundamentaldiscoveriesaboutthehumanorganismandthe
agingprocessitself.
Wethinkofourselvesaslivinglongerthanourforebears,butin
factthebiologicallimithasn'tchanged.Tombstonesin
eighteenthandnineteenthcenturycemeteriesarewitnesstothe
frequencythenofinfantandchildhoodmortality,deathsin
epidemicsanddeathinchildbirth.Buttheagesofthosewhodid
reach"oldage"arenotdifferentfromagestoday.Advancesin
medicineandpublichealthhaveprimarilyextendedtheaverage
lifeexpectancybyallowingmorepeopletoreachtheupperlimit
oftheirbiologicalpotential.Alargerproportionofthe
populationreachesoldagethesedays,buttheupperlimitoflife
expectancyhasnotbeendramaticallyaltered.Ifthetwoleading
causesofdeathtodaycardiovasculardiseaseandcancer
wereconquered,overalllifeexpectancywouldstillincreaseby
onlyafewyears.
Giventhebiologicallimittolongevity,thelikelihoodof
attainingthatagedependsuponmanythings.Diseases,although
differentonesfromthosethattookourforebearstoearlygraves,
arestillimportant.Butother,lesstangible,circumstances,
generallylumpedunderthelabel"psychosocialvariables,"seem
tomatterasmuch,sincetheyaffectmortalitytoalargedegree.
Forexample,atanygivenagemorethantwiceasmanypeople
fromthe"lowest"socialclassdieasfromthe"highest"social
class.Andmenwithlessthaneightyearsofschoolinghavea50
percenthigherdeathratethanthosecompletingoneormore
yearsofcollege.(1)
Becausepsychosocialvariablescanexertalargeinfluenceon
anyanalysisofmortality,avalidstudyoftherelationship
betweenphysicalactivityandlongevitymusttakealonglistof

themintoaccount.Studiesthatdon'tandthatisnearlyallof
themaresimplisticandunreliable.
Besidessocialgroupandeducationalstatus,thebest
documentedpsychosocialvariablesthatinfluencelongevityare
income,occupationalstatus,worksatisfaction,socialactivity
andlifesatisfaction.Peoplewhoaremoreprosperous,whohold
higherlevelpositions,whofindtheirworkandtheirsociallives
interestingandgratifyinglivelonger!
Socialinteractionseemstobeoneofthemostimportant
predictorsoflongevity.Menandwomenwiththemostsocial
connectionslivelongest,whilethosewhoselifestylesisolate
themfromotherpeoplearemorelikelytodiesooner.The
elderlychurchvolunteerwhobustlesaboutatthechurchbazaar
islikelytobelivinglongerbecausesheissociallyactive,not
becausesheisphysicallyso.Marriedpeoplelivelongerthanthe
unmarried,thewidowedandthedivorced.Evenpetsmay
provideaformofsocialinteraction;peoplewithpetslive
longer,too.
Anunderlyingreasonmaybethatpleasantsocialinteractions
tendtoreducestress.Stresshasbeenglaringlyimplicatedasan
unhealthyingredientinourlives.Althoughafewpeopleseem
tothriveonstress,andamoderateamountofpressuremayhave
somebeneficialeffect,largerdosagesformostpeoplecan
producedestructivechangesintheirbodies'hormoneandother
chemicalbalances.Thesechangesmay,inturn,affect
susceptibilitytodiseaseorhampertheabilitytofightoffdisease
onceitoccurs.Thefirstyearofretirementandthefirstyearof
widowhoodhardtimesforallofusarebothassociatedwith
ajumpinmortalityrates.Eventhesurprisingparallelofhigher
deathrateswithunemploymentprobablyhasitsoriginin
tensionrelatedillnessandphysiologicalvulnerability.Astudy
of1,200centenarians,Americansfromfarmerstobankerswho
livedtobeatleastonehundredyearsold,showedabsenceof

stress,forwhateverreason,tobethemostfundamentalcommon
denominatorintheirlonglives.(2)
Heredity,nutrition,habitsandenvironmentareotherfactorsthat
affectthelengthofourlives.Ifyourparents,yourGreatAunt
MatildaandyourGrandfatherJonesalllivedtobeninety,you
canmakeafairguessthatlongevity"runsinthefamily."What
youeatandwhetheryousmokeordrinkalcoholinmorethan
moderateamountsaffecthealthingeneral,andtherefore
longevity.Mortalityratesvarybywhereapersonlives,partly
becauseofsuchfactorsasindustrialpollution,butalsobecause
ofsuchmeasuresasthepaceoflife,thesocialintegration
possibleandtheextentofcommunitysupportsystemsofall
kinds.
Clearly,theissueoflongevityisenormouslycomplex.Somany
thingsmanyofwhicharepoorlyunderstoodandverydifficult
tomeasureareinvolvedthatpredictingthelifespanofany
individualisvirtuallyimpossible.Ifmarriageitselfisprotective,
doesa"bad"marriageworkjustaswell?Andifnot,howhappy
mustthemarriagebe,andhowdoyoumeasurethat?Aperson
mightbedelightedwithhisjobasacoalminer,buteasily
contract"blacklung"inhisforties.Mrs.Smithmightvolunteer
foreverycommitteeinsightoutofstridentcontemptforthe
incompetenceofhercoworkers,sothatthefactofher
membershipisapoormeasureofhersocialinteraction.
Intothismorassofilldefinedandunquantifiableelementshas
beendroppedthecomplicatedquestionofexerciseandits
relationshiptolongevity.Howeverillfounded,theideathat
exerciseisprotectiveandlifeenhancingiscompelling.
Children,whocanrunaboutallday,strikeusas"fulloflife,"
andwesayofanactiveolderpersonthatsheis"brimmingwith
vitality."Whenwearefulloflife,itoftenbrimsoverintheform
ofactivity.Whatismorelogical,then,thantobuildfromthis
thenotionthatexerciseputsmorelifeintoaperson?Theideais

acceptedbymostpeopleasabiological''given."Thereisan
almostunassailablebeliefthatexerciseaddsmorelife,andthat
wewillthereforenotdiesoearly.Theideahasasimpleand
intuitivelogic,aseductive,magicalquality.
Studiesoftherelationshipbetweenphysicalactivityand
mortalitydealalmostexclusivelywithdeathfromcoronary
disease,andwithgoodreason.Cardiovasculardiseaseisthe
leadingcauseofdeathinindustrializedsocieties,andany
measurableimpactonlifeexpectancywouldhavetoaffecta
majorcauseofdeath.Physicalactivityis,moreover,dependent
uponthecardiovascularsystematleasttotheextentthatthe
heartpumpsthebloodandthearteriescarryitaroundthebody
sothecellscanusetheoxygeninittoprovideenergyfor
activity.Noonehasevensuggestedalinkbetweenphysical
activityandothermajorcausesofdeath,suchascancerorcar
accidents.
Researchinthisareaisthoroughlyconfused.Instudyafter
studyofphysicalactivityandmortality,resultsareso
contradictorythatanyconclusionthatcouldbedrawnfrom
themamountstonomorethanunsubstantiatedopinion.
Thespecificbeliefthatexercisemakesyoulivelongerbecause
itprotectsyoufromcoronarydiseasewasfirstlegitimizedby
JeremyMorris's1953landmarkstudyofLondontransport
workers.Morrisanalyzedthehealthrecordsofabout31,000
maleLondontransportworkers,agesthirtyfivetosixtyfour
years,inorderto"seekforrelationsbetweenthekindofwork
mendo...andtheincidenceamongthemofcoronaryheart
disease."Theworkersweredividedintotwooccupationalwork
groups,conductorsanddrivers.Londonbusconductorsarea
prettyactivegroup;theyswingupanddownthestairsofthe
doubledeckers,helplittleoldladieson,rushtotellpeople
wheretogetoffandmanagetocollectallthefaresinthe
meantime;thedrivers,ontheotherhand,justsitbehindthe

wheelanddrive.Theresultsofthedataanalysisshowedthat
conductorshadlesscoronaryheartdiseasethanthedrivers;
whenthediseasedidappearinconductors,itwasatalaterage
andwaslesssevere;andconductorslivedlonger.Morrisandhis
colleaguesfocusedonthegreaterphysicalactivityof
"conducting"toexplainthelowerincidenceandmortalityof
coronaryheartdisease.
Physiciansquicklyacceptedtheseconclusionsasscientificfact.
Theimpactwassuchthatmostsubsequentstudiesofthe
relationshipbetweenactivityandcoronarydiseaseand
longevity,eventothisday,citeMorris'soriginalstudyasa
foundation.Theforceofthe"facts"wassogreatthat,although
Morrisandhiscoworkersrepudiatedtheiroriginalconclusions
withinonlythreeyearsweshallseewhyothersstillsought
toconfirmwhathadneverbeenproveninthefirstplace.
Supportfortheideathatphysicalactivityenhancedlongevity
andreducedcoronaryheartdiseaseappearedregularlyin
medicaljournalsduringthe1960s.Bythefollowingdecade,the
medicalprofessionwas,literally,offtotheraces.
In1962,H.L.Taylor,oftheUniversityofMinnesotaSchoolof
PublicHealth,analyzedrecordsof191,609menemployedin
theAmericanrailroadindustry,anindustrychosenbecauseit
offered"favorableconditionsforstudy."(3)Railroadworkers
rarelychangejobs,sotheeffectsofotheroccupational
influencesareminimized.Sincedetailedrecordsareusually
maintained,dataondeathratesareconsideredreliable.Taylor's
analysisshowedlowerdeathratesformoreactivepeople,
supportingtheideathatmeninsedentaryoccupationshave
morecoronaryheartdiseasethanthosewhoseworkrequires
moderatetoheavyphysicalactivity.
Ananalysisofabout110,000adultsenrolledintheHealth
InsurancePlanofGreaterNewYork,andclassifiedbyactivity
levels,waspublishedin1969.(4)Theleastactivegrouphad

twicetherisk(8.5per1,000comparedwith4.2per1,000)of
sufferingafirstheartattackcomparedwiththenextactive
group;anddyingfromthatheartattackwasalsomorelikelyfor
theleastactiveindividuals.Thedifferenceswereonlybetween
sedentarymenandthosemoderatelymoreactive.Therewasno
furtherdecreaseinriskformoreactivepeople.
In1975,Dr.RalphS.Paffenberger,Jr.,ofStanfordUniversity
SchoolofMedicine,analyzedthehealthrecordsof6,351San
Franciscoarealongshoremen.(5)Tryingtocorrelatework
energyexpenditurewithcoronaryattacksandcoronarydeaths,
hefoundthatonlythoselongshoremenleadingaveryenergetic
worklifehadsignificantprotectionfromcoronaryattacks;lesser
degreesofenergyexpenditurewerenotprotective.
Dr.Paffenbergerlateranalyzed16,936questionnairesof
supposedlyhealthyHarvardalumniwhohadenteredtheschool
from1916to1950.(6)Heestimatedenergyexpenditurefromthe
activitiestherespondentsreportedeverythingfromreadingto
squash,fromdoingnothingtodistancerunningandcompetitive
teamgames.Thedatareportedlyindicatedthathighlevel
energyexpenditurewasprotectiveagainstfatalandnonfatal
coronaryheartdisease,butanythinglessthanhighlevelenergy
expenditurewasoflittleornoprotectivevalue.
About20yearsafterMorris'sappealingfindings,thepopularity
ofrunningbeganreallycatchingon.Sincethe1972Olympic
Games,whenmillionsoftelevisionviewerssawFrankShorter
becomethefirstAmericanin64yearstowinthemarathon,
interestandinvolvementwithrunninggrew.TheNewYork
RoadRunnersClub,whichhadstartedin1958with42
members,had,by1976,some1,700members;itnownumbers
about22,000.The1970NewYorkMarathonattractedonly126
runners,andalmostfivetimesthatnumbertenyearslater.In
1975,theNewYorkRoadRunnersClubbeganclassesand
clinicstopromoteandprovideinstructioninrunning.Ahighly

successfulmagazine,TheRunner,beganpublicationin1978,
andthreebooksonrunningwereontheNewYorkTimesbest
sellerlistformuchofthatsameyear.
Intherunningglorydaysofthe1970s,aquiteextraordinary
ideawasintroducedtothemedicalprofessionandthen,rather
quickly,totherunningworldatlarge.Popularlyknownasthe
"MarathonHypothesis,"thenotionwasformulatedbyDr.
ThomasJ.Bassler,apathologistinCalifornia.Asoriginally
proposedbyDr.Bassler,himselfadevotedmarathoner,the
thesisstatedthatmarathonrunningconferredabsolute
protectionagainstdeathfromcoronaryheartdisease.(7)
Duringtheensuingyears,theMarathonHypothesiswasquoted
andmisquoted,definedandredefined,asvariouspeopleusedit
tosupportordenyoneoranotherproposition.Theresulting
confusionarisespartlyfromthefactthatDr.Basslerhimselfhas
restatedtheidearepeatedly,butwithdifferentwordsandwith
differentemphasis.Originally,thepropositionseemedtobethat
marathonrunningitselfprotectsonefromdeathduetocoronary
heartdisease.Morerecently,Dr.Bassler'sfocushaschanged;he
nowcreditsthelifestyleofthemarathonrunner,ratherthanthe
runningitself,withconferringthisremarkableimmunity.
Accordingtohim,anypersonwhoselifestylepermitshimto
completea42kilometerraceatraditionalmarathonis
immunetodyingfromcoronaryarterydisease.Othershave
takenthepropositionevenfartherafield.Believeitornot,even
thenotionofimmortalityasaconsequenceofmarathonrunning
hasbeensuggested.
Thus,withMorris'soriginalpublicationin1953,thesubsequent
apparentconfirmationsduringthe1960sand1970s,andthe
dramaticimpactoftheMarathonHypothesisadecadeago,the
ideathatphysicalactivityislifeenhancingwasfirmly
established.Thecaseforlongevityhadcomealongway.

Intuitivelyappealingideasthathavebothlogicalandmagical
qualitiesperhapsaretoodifficulttodispel.Butitstillseemsodd
inretrospectthatthesestudiesandideaswerenotsubjectedtoa
morecriticaleyeandthatmorecredencewasnotgivento
similarstudiesthatfailedtoshowaconnectionbetween
physicalactivityandlongevity,orevenshowedthatastrenuous
lifecouldleadtoanearlierdeath.
MaybetheenthusiasmgeneratedbyMorris'soriginalstudywas
toogreattosuggestamorecriticalappraisal.Afterall,if
physicalactivitycouldreducetheincidenceandseverityofwhat
wasbecomingrecognizedasanepidemicofcoronaryheart
disease,itwaswithinthepowerofeachofustopreventthis
epidemicfromspreadingtothosewecaredforandtoourselves.
Thiseasyanswerbemoreactivewastooappealingto
generatesufficientcontroversyandconflict.
Buttherewerereasonsenoughtoquestionthevalidityofthe
conclusionsthattheexerciseenthusiastshadreached,ifonly
anyonehadwantedto.
Fromthebeginning,Morrisandhiscolleagueslistedother
possibleexplanationsfortheirbusdriverandconductordataand
werequitehonestinannouncingtheirbias.Theychosetofocus
onthe"greaterphysicalactivityofconducting"asthecauseof
thelowerincidenceofcoronaryheartdiseaseandmortalityin
thatgroup,and"decidedtoignore...theotherfactorsinthe
constitutionofthemenandintheirhistorythatmustcertainly
alsobeinvolved."These"otherfactors"theylistedbutchoseto
ignoreincluded:"differencesintheconstitutionandearly
experienceoftheconductorsanddrivers,anotherexpressionof
whichisthatthemenselectforthemselvestheseverydifferent
jobs."
These"differencesintheconstitution"andtheconsequentself
selectionofdifferentjobsbydifferentpeopleare,infact,central

toacriticalanalysisofMorris'sdata.For,ashehimselffound
andpublishedin1956,onlythreeyearsafterhisoriginalreport,
theconductorsanddriverswerereallynotsimilarpeoplefrom
theoutset.(8)Thebusdriverswerefatter;theirgirthandweight
weregreaterthanthatofconductorsevenatthetimetheywere
firsthired.Andifbeingfatterwentalongwiththingslikehigher
cholesterollevelsandbloodpressure,asseemslikely,thenthese
couldhaveexplainedthedifferencesintheriskofdying
observedlater.
Thisselfselectionofcertainoccupationsandactivitiesby
peoplewhoalreadyhavecertaincharacteristicsthataffect
longevityisaproblemthatplaguesallsuchstudies.Itconfounds
theanalysisoftherelationshipofactivityitselftolongevity,
sincetheseothercharacteristicshavealreadyinfluencedthe
choiceofactivity.Thatthiswasnotaflukeoranisolated
aberrationofMorris'sstudywasshownbyareportin1967by
R.M.Oliver,ofGreatBritain,whostudiedthephysiquesand
levelsofbloodfatsofrecruitsforthejobsofbusconductorand
busdriverinLondonbeforetheactivityofthejobitselfcould
affectthemen.(9)Heconcluded:"ItisapparentthatBritishmen
withcertainphysicalcharacteristicschooseorarechosento
becomebusdriversasopposedtoconductors,"andaddedthat
hisstudy"supportstheviewthatinheritedcharacteristics,oneof
whichmaybesusceptibilitytoheartdisease,maypredisposeto
aparticularoccupation."
Thisselfselectionofactivitybyvirtueofinheritedorotherpre
existingcharacteristicsaffectsstudiesrelatinganytypeof
activity,occupationalorrecreational,tohealthandlongevity.
Thefathersofmarathonrunners,forexample,haveless
coronaryheartdiseasethanthefathersofindividualswhoare
notmarathoners.Sincethosewhochoosetorunmarathonshave
lessinheritedfamilyhistoryofcoronarydiseasethando
nonmarathoners,thisalreadymakesthose42kilometermenless
pronetocoronarydiseaseandmortality,eveniftheynevereven

rantocatchabus.
Similarselfselectionoperatesintheareaofbloodcholesterol
levels.Althoughreportsindicate,forexample,thatrunning
favorablyaffectscholesterollevelsforcardiovascularhealth,it's
alsotruethatevenbeforetheybegintorun,individualswho
choosetobecomerunnersalreadyhavebettercholesterollevels
thanthosewhochoosenottorun.Peoplewithcertain
preexistingcharacteristicsorqualitiesselectcertainactivities
andlifestyles,althoughwedon'tknowwhy.Itisthesepre
existingcharacteristics,ratherthantheactivitythattheyseemto
leadto,thatmaybebeneficial.
InTaylor's1962studyofAmericanrailroadindustry
employees,otherproblemsaffectedthevalidityofhis
conclusions.Lowerdeathratesinmoreactivepeopleturnedup
onlyinworkersofcertainagegroups.Forinstance,onlyamong
sixtytosixtyfouryearoldswereoveralldeathsmorecommon
inthemostinactivethaninmoderatelyactiveworkers.Forall
otheragegroups,overalldeathratesweresimilar.Whenthe
mostinactivewerecomparedwiththemostactive,overall
deathswereloweronlyamongactiveworkersagedfiftyfiveto
fiftynineandsixtytosixtyfour.Fordeathsduesolelyto
coronaryheartdisease,theleastactivemenhadhighermortality
ratescomparedwithmoderatelyactivemeninagegroupsforty
tofortyfour,fiftyfivetofiftynineandsixtytosixtyfour,but
deathratesweresimilarforagesfortyfivetofortynineand
fiftytofiftyfour.Andcomparingcoronarydeathsoftheleast
activewiththemostactiveworkers,deathratesfortheleast
activewere.higherforagesfortyfivetofortynine,fiftyfiveto
fiftynineandsixtytosixtyfour,butwerenotdifferentforthe
agesoffortytofortyfourandfiftytofiftyfour.Sincethereis
nologicalorbiologicalreasonforthesefigures,chanceor
somethingelsecompletelyunrelatedtophysicalactivityseems
themorelikelyexplanation.Furthermore,therearenodatato
indicatethattheserailroademployeeswerereallyrepresentative

oftherestofthepopulation.Forallweknow,andasTaylor
himselfsuggested,theymayhavebeenauniquegroup,with
manycharacteristicsnotsharedbytherestofus.Perhapsmost
important,moreofthesedentaryworkerslivedinurbancenters,
wheredeathratesarehigheranyway,andthemostactivegroup
wereapttoliveinsmallcommunities,wheredeathratesare
generallylower.Thisalonecaninvalidatetheconclusionthat
thelevelofphysicalactivitycausedtheobserveddifferencesin
mortalityratesamongthedifferentworkers.
Inthe1969HealthInsurancePlanstudy,datawereobtainedby
reviewingthemedicalrecordsof110,000peopleenrolledinthe
healthplan.Mostofthosewhometthecriteriaforcoronary
heartdiseasewerespeciallyexaminedandinterviewed.To
determinethecharacteristics,includingphysicalactivity,ofthe
population,arandom12percentoftheentire110,000people
receivedaquestionnaireduringthethreeyearsofthestudy,but
only83percentresponded.Only156patientshadaspecial
examinationandaninterviewandansweredthemailsurvey
questionnaire.Howpeopledescribedtheiractivitylevelswhen
probedbyaninterviewerdidn'tcorrespondwellwithwhatthey
hadfilledoutonthemailedform,forcingthestudy'sauthors
themselvestoadviseconsiderablecautionininterpretingthe
findings.Also,othervariables,includingcholesterollevelsand
psychosocialfactorsthatmighthaveinfluencedtherisk
associatedwithphysicalinactivity,weren'tevenconsidered,and
theseandotherunidentifiedfactorsmighthaveindependently
contributedtobothinactivityandheartattacks.
Thelongshoremenstudyin1975conspicuouslyignoredthebias
ofjobselfselection,whichtheLondontransportworkersstudy
hadshowedtobesoimportant.Also,becauseitwaspossible
thatmenhadrecentlychangedjobsduetopoorhealth,deaths
wererelatedtothejobsheldsixmonthsbeforetheydied.Butit
seemsmostplausibletomethattheonsetofsymptomsof
coronaryheartdiseasewouldusuallycomemorethansix

monthsbeforedeath.Sopeoplewhomayhavebeenveryactive
whentheirheartdiseasebeganwerelistedasinactivewhenthey
died.
Thelongshoremen'ssunionregulationsdivideeachworking
houroftheheavyworkgroupinto55percentworkand45
percentrest,andforthelightworkgroup,75percentofeach
hourisdevotedtoworkandonly25percenttorest.Whilethe
authorscreditthe"repeatedburstsofpeakeffort"forthelower
coronaryriskamongheavyworkers,Ifinditdeliciously
appealingtocredittheirlongerrestperiods.Certainlythestudy
failedtoconsiderfactorssuchaslackofjobsatisfaction,less
conviviality,eventhesheerboredomthatsedentaryworkmight
haveentailed.
IfDr.Paffenburger'slongshoremenstudywasflawed,sowas
hislaterHarvardalumnistudy.Forsomereason,thosewho
answeredthequestionnairewereconsiderablyhealthierthan
alumniwhofailedtorespond.Thefactthatthosewhodid
respondweren'trepresentativeofHarvardalumniingeneralwas
easytotell:Harvardkeepsrecordsofallalumnideaths,andas
theyearspasseditturnedoutthatthosewhohadrespondedto
thesurveyweren'tdyingoffasfastasthosewhohadn't.That
shouldteachusalessoninstatistics.Ifyouwanttolivelonger,
thenumbersseemtosay,answeraHarvardalumni
questionnaire.
Independingonquestionnaireinformationaboutphysical
activity,thestudyreliedonamailsurvey,amethodtheHealth
InsurancePlanstudyandothershaveshowntobeunreliable.
Thequestionnaire,anyway,failedtoincludequestionsabout
personality,stress,levelsofbloodfatandotherfactorslikelyto
beimportantincoronarydiseaseandoveralllongevity.
Moreover,aboutoneoutoffiverespondentswhoclaimedto
havenoheartdiseaseactuallydidhavecoronaryheartdisease.It
seemslogicalthatthosewhohadheartdisease,whetherthey

wereunawareofitorsimplypreferrednottoreportit,would
neverthelesshaveloweractivitylevels,eitherbecauseof
symptomlimitationsuchaspain,breathlessnessordizziness,or
becauseofthosesubtleandstillunidentifiedfactorsthatmake
sickpeopledoless.TheseHarvardmenwouldhavean
increasedmortalityrateduetotheirpreexistingheartdisease,
butinthestudyitwouldbeattributedtotheirinactivity.
Allthispickingawayatstudiesthatimplythatyoucanlive
longerifyouexercisemightseemtrivialifallthestudiesaround
cametothesameconclusion.Butmanyinvestigationsshowno
differenceatallindeathratesofmuscled,sinewy,outdoorsy
typescomparedwithsedentarydeskworkers.Thereareeven
studiesdemonstratingearlierdeathformoreactivepeople.
A1970studyofItalianrailroadmenshowedthatneitheroverall
deathratenorcoronaryheartdiseasedeathratewasrelatedto
occupationalphysicalactivity.(10)AnotherlookatUnitedStates
railroadmenindicatedthatdeathratesfromallcauseswere
higheramongphysicallyactiveswitchmenthanmenin
sedentaryoccupationseventhoughthecoronarydeathratewas
loweramongthemoreactivemen.Andwhatdifferencesthere
werewerethoseyoumightfindbychancealone.Aseven
countrystudyconcludedthatiflevelsofphysicalactivityor
inactivitywererelatedtocoronaryheartdisease,itwassucha
minorassociationthatitprobablycouldn'tevenbeproven.(11)
Sixyearslater,ananalysisof172,459Italianrailroadworkers
alsofoundoveralldeathratesfromallcauseshigheramongmen
performingheavyworkcomparedwithmoderateandsedentary
workers.(12)Again,sedentarypeoplehadincreasedmortality
fromcoronaryheartdisease,buttheheavyworkgroupdied
soonerof"degenerativeheartdisease,"acatchalltermthat
includesmanycasesofcoronaryheartdisease.
Dr.JohnM.Chapmanandhiscolleaguesfound,ina1957study

of2,252LosAngelescivilserviceemployees,30percentfewer
newcasesofcoronaryheartdiseasethanexpectedbasedonage
inasedentarygroupofworkers,and38percentmorecasesthan
expectedinaheavyexertiongroup.(13)Overall,therewere25
percentmorenewcasesofcoronaryheartdiseaseanddeaths
fromcoronarydiseaseinthetwohighestlevelsofphysical
activitycomparedwiththetwolowest.
A1967analysisofIndianrailwayworkersintheBritishHeart
Journalreportedthat"anunexpectedandextraordinaryfinding
inourdataisthatmortalityinthesedentaryoccupationofclerks
islowerthanthephysicallyactiveoccupationoffitters...this
iscontrarytothecurrentconceptionsoftheprotectiveroleof
exercise."(14)Heavierlevelsofphysicalactivityconferredno
evidentprotectionorbenefit;thehigherlevelsofactivitywere
associatedwiththegreatestdeathrates.
InaScandinavianstudyin1976comparingseverallevelsof
activityofFinnishmen,totalmortalitywashighestformen
doingthemostvigorousphysicalactivity.(15)Coronaryheart
diseasemortalitydidn'tgenerallycorrelatewellwithhabitual
physicalexertion,butwasclearlyhighestforthemostactive
men.Theauthors,membersoftheFinnishHeartAssociation,
offeredthepossibility"thatvigoroushabitualphysicalactivity
whichexceedsacertainthresholdisdeleteriousor,atleast,does
notfurtherreducetheriskofcoronaryheartdisease."
Nodoubtthesestudiescouldalsobepickedaparttorevealtheir
flaws.Allsuchratherunsophisticatedusesofstatisticsare
powerlesstoexplainsocomplicatedathingaswhyoneperson
diesofaheartattackatfifty,andhisneighborlivesontobeone
hundred.Studiesthatclaimthatphysicalactivityconfers
longevityareinevitablyfaultyindesign,andjustasmuch
contradictorydatacanbeaccumulatedbythesamemethods.
JeremyMorris,whomaintainedhisbeliefthatphysicalactivity
protectedagainstcoronaryheartdisease,wasneverthelessa

candidman."Theevidenceonthisproblemisquiteconflicting,"
headmitted."Inseveralstudiescoronaryheartdiseasehasbeen
foundtobeassociatedwithphysicalactivity/inactivityinthe
expectedway.Inasmany,norelationshipwasdemonstrated,or
anequivocaloroppositeone;andwhythisissoisstillquite
unclear."(16)
Thereisonesimpleexplanationofwhytherelationshipbetween
activityandlongevityisunclear.Theymaynotberelated.How
muchyouexerciseandhowlongyoulivemaynotbeconnected
atall.
Ifyoustartwiththebeliefthatexerciseisbeneficialtolife,then
contraryorconflictingdatawillcertainlybetroublingand
puzzling.Butifyoustartwithnoparticularassumption,ifyou
approachthesubjectwithanopenmind,suddenlythereisno
problem.Somepeoplewhoexerciselivealongtime,some
don't;somesedentarypeopledieyoung,otherslivetotheir
biologicallimit.Thereisaboutthesamerelationshipbetween
activityandlongevityasyoumightfindifyouweretocompare
theamountofchocolatepuddingchildreneatwiththelikelihood
oftheircomingdownwithchickenpoxthatis,norelationship
atall.That'sthemostreasonableinterpretationofthe
"conflicting"resultsfromallthestudies.
Unfortunately,littlereasonhaslitthismurkysubject.IfMorris's
Londontransitworkerstudyhadshowneithernoprotection
fromexerciseoractualdeleteriouseffects,aslaterstudiesdid,
thenthedilemmaoftodaywouldnotexist.Theburdenofproof
wouldbeonthosetryingtoestablishaprotectiveeffectof
exercise,somethingtheyinalllikelihoodcouldn'tdo.Instead,
however,theprotectiveeffectofexerciseiswidelyacceptedas
abiologicalfact,andtheburdenofprooffallsonthose,likeme,
whodoubtit.
Faultingthemethodologyofstudiesthatpurporttoshowlife

extendingbenefitsofexerciseandlayingoutanequalarrayof
datacontradictingthatnotionisstillnotenoughtodispelthe
ingrainedideathatexercisemustsomehowbegood.The
exercisebelievershaveafallbackposition:Sincecoronary
diseaseisaninsidiousaffair,usuallyunfeltandundiagnosed
untilitiswelladvanced,perhapsexercisecannotreallyundoit
onceitiswellestablished.Butmaybeexercisecanaffectits
course,delayitsappearance,retarditsprogression.Perhaps
exercisebenefitsusinalessobviousbutneverthelessimportant
way.Ifwecouldjustfind,forexample,thatexercisedid
somethingtothewayfatspileupinourarteries,ortotheway
ourarteriesrespondtodamage,ortoanythingelseweknow
contributestocoronaryarterydisease,wemightthenstillhavea
treatmentweshouldrespectandrecommend.

5. The Inside Evidence

Exerciseenthusiastsmaywellobjecttohavingtheirclaimsto
longevitydispelledbyattacksonnumbersandmethods,andby
citingcontradictorystudiesdoneinthesamemanner.Statistics
aretricky,andhardenoughforepidemiologiststohandle.What
abouttheeffectsofexerciseonthingsthatleadtohearttrouble,
andwhataboutthephysicalevidence,theactualheartsand
arteriesofthosewhoexerciseandthosewhodon't?
Scientistsandresearchershavesometimestriedtolookat
exerciseasitmightaffecttheheartatdifferentstagesinthe
developmentofcardiovasculardisease.Thereisacertainlogic
tothis,foritcouldbethatexercisemighthavedifferenteffects
onyourcardiovascularsystematdifferenttimesinyourlife.
Perhapsifstartedearlyenough,somepeoplereason,vigorous
activitycouldpreventorforestallthedevelopmentof

atherosclerosis,theaccumulationoffattydepositsinthearteries.
Otherssaythatifsuch"primaryprevention"doesnotoccur,
thenexercisingaftercoronarydiseasehasdevelopedmight
providesecondaryprevention"byslowinguptheprogressofthe
diseaseandminimizingitsconsequences.Somecardiovascular
researchersfurtherrefinethatthesis,andconsidersecondary
preventiontobe.preventionatthestageofearlyvascular
disease,beforethereareanysymptomsorsignsofit,and
"tertiaryprevention"tobepreventionafterthereisclinical
evidenceofdisease,suchasanginapectorisoraheartattack.
Asfarasprimarypreventiongoes,thereisnogoodevidence
thatrelatesphysicalactivityorthelackofitinearlylifetothe
developmentofcoronaryatherosclerosis.Autopsiesofyoung
AmericansoldierskilledintheKoreanandVietnamwarshave
shownasurprisinglyanddisquietinglyhighincidenceofearly
atherosclerosis.Yetsurelymostsoldiers,tested,trainedand
forcedbycircumstancetomaintainstrenuouslevelsofexertion,
arephysicallyactiveyouths.Judgingbyarteriesalone,however,
therewasnocluethatsuchalifehadanyinhibitingeffectonthe
earlystagesofcoronarydisease.Goingbackevenfurther,to
activitylevelsduringchildhood,Dr.G.R.Osborn,aBritish
pathologistattheUniversityofSheffield,hasstudiedthe
coronaryarteriesofinfantsandyoungchildrenkilledby
traumaticandothernoncardiaccauses.(1)Afteryearsof
painstakingandmeticulousworkonthearteriesofover1,000
subjects(someadult),Dr.Osbornhasidentifiedmicroscopic
injuriestothearterywallsininfancythathebelievestobethe
originsofatheroscleroticdisease.Theseinjurieshavenothingto
dowiththelevelsofphysicalactivityofinfantsandchildren.
Anotherway,perhaps,oflookingatpossibleprimaryprevention
ofatherosclerosisbyexerciseistolookattheeffectsoflackof
exercise.Canoneatleastguessthattherearebenefitsfrom
activitybyshowingthatinactivityleadstocoronaryheart
disease?Thereisperhapsahintthatinactivityisrelatedto

coronaryatherosclerosis.Butbyallindications,youmustbe
trulysedentaryaslugwhositsorliesaboutallday,orbarely
crawlsfrombedtobreakfast,tocaranddeskandbackagain
tobeatanyriskfrominactivity.Noonewhohastopusha
vacuumcleaner,playballwiththechildrenorkeepthelawn
mowedisthatinactive.
Sincetheevidenceforpreventingtheearlystagesofcoronary
heartdiseasebyexercisingisvirtuallynonexistent,whatabout
secondaryandtertiaryprevention?Canexerciseslowdownthe
progressofatherosclerosisonceithasstartedorpreventmore
heartattacksonceyouhavehadone?Canexercisepreventthe
arrhythmiathatcausesthesuddencardiacdeathofpeoplewith
coronaryheartdisease?
Thesearecrucialquestionsbecauseexerciseprogramsare
becomingwidelyusedintreatingcardiacpatients.Cardiac
"rehabilitation"isthenewbuzzwordincardiology.Patientswho
havehadheartattacksarebeingenrolledataneverincreasing
rateinexerciseprogramsontheassumptionthattheywillavoid
repeatedheartattacks,oriftheydohaveanotherattack,itwill
belesssevere.Theveryword"rehabilitation"impliesrepairof
theheart,andpeoplewhopaymoneyforsuchpromisesatleast
expectnottobekilledstraightoffbytheirdisease.
Suchpromisescan'tbekept.Thephysicalconditionofheartand
arteriesatanystageofdiseasedoesn'timprovewithexercise.
Eventhebestdesignedandbestcontrolledstudiesshowno
reductioninfrequencyorseverityofheartattacks,noslowingof
thediseaseprocessandnoprotectionfromsuddendeath.
A1975reportfromSwedencovered315heartattackpatients
whowererandomlyassignedeithertoanexercisetraining
programortonoprogram.(2)Therewasnoevidentinfluenceof
exerciseoneitherthedeathrateortherateofrecurrentheart
attacks.

A1981Canadianmulticenterstudyincluded733menwho
survivedaninitialheartattack.(3)Afteryearsoffollowupon
matchingindividualsrandomlyassignedtoeitherahigh
intensityoralowintensityexerciseprogram,therewasfoundto
benosignificantdifferenceineithertherateofsubsequentheart
attacksorthedeathratebetweenthehighintensityandthelow
intensitygroups.Inactualfact,whereas9.5percentofthehigh
intensitygrouphadrepeatheartattacks,only7.3percentof
thoselessactivedid.
AfiveyearWorldHealthOrganizationstudyof375survivors
ofaheartattackwhowererandomlyassignedtoa
"comprehensiveinterventiongroup"ortoacontrolgroup
showedthattotalmortalitywasnotsignificantlydifferentforthe
interventiongroupthanforthecontrolgroup.(4)Coronary
mortalitywasreducedintheinterventiongrouplargelybecause
offewersuddendeathsinthefirstsixmonthsaftertheheart
attack.Sincethesepatientsreceivedmoreprotective
cardiovascularmedicationsthanpatientsinthecontrolgroup,
thereductioninmortalityspeaksonlyforthebenefitsofa
comprehensivetreatmentprogram,notforexercisealone.
Incidentally,thereweremorenonfatalrecurrentheartattacksin
theinterventiongroupthaninthecontrolgroup,andresearchers
couldn'tfindanydifferenceineithergroup'scapacitytodo
physicalwork.
Anambitiousstudy,theNationalExerciseandHeartDisease
Project,wasplannedintheUnitedStatesafewyearsagoto
makeadefiniteassessmentofthetherapeuticeffectsofexercise
byfollowingaverylargegroupofpatients.(5)Althoughthesize
oftheoriginallyproposedpatientsamplewaseventuallyscaled
down,651patientswhohadsurvivedaninitialheartattackwere
randomlyassignedtoexerciseortonoexercise,andfollowed
overathreeyearperiod.Theresults,simplyput,showedno
significantdifferenceintherateofrecurrenceordeath.

Thesestudiesareadmittedlyimperfect.Theirdesign,likethatof
othersuchstudies,canbefaultedandthenumberofsubjects
analyzedisrathersmall.About27percentofpatientsare
excludedfromexercisetrainingprogramsafteraheartattackfor
othermedicalreasons,suchasheartfailure,uncontrolled
hypertensionorarrhythmias.Patientsdropoutoftreatment
groupsunpredictably,andprobablysomepatientswhoarenotin
theexerciseprogramexerciseanyway.Despitetheirlimitations,
however,theyarethebeststudiesavailable,andtheinescapable
conclusionisthattheyshownosecondarypreventionatthe
earlystagesofdisease,notertiarypreventionaftersymptoms
areobviousinfact,nobenefitsfromexerciseatall.
Whentheclaimsofprimary,secondaryandtertiaryprotection
againstcoronaryheartdiseasearedismissed,thereisstilla
traditionalandwidelyheldviewthatexerciseincreasesthe
coronarycollateralcirculation.Collateralbloodvesselsare
supplementarychannelsthatprovideconnectionsamongthe
mainarteriesandtheirbranchesandresultinanincreasein
bloodflow.Coronarycollateralsconnectbranchesofeachmajor
coronaryarterytootherbranchesofthesameartery,andthey
provideconnectionsamongbranchesofthedifferentmajor
coronaryarteries.Thissupplementarysystemisofgreat
importanceinkeepingupaflowofbloodtotheheartmuscle
whenthemajorcoronaryarterieshavebecomenarrowedor
totallyclosedoffbyfattydeposits.Ihaveseenpatientswhose
originalmajorcoronaryarterieswerecompletelyobstructedby
atherosclerosis,yetwhosebloodflowthroughtheirheartmuscle
wasnearlynormalduetotheircollateralcirculationnetwork.
Thefineinterweavingcollateralchannelsmaybesoextensive
thattheheartlookslikeitiscoveredwithspiderwebs.
Foryearsexerciseadvocateshavesuggestedthatexercise
promotesthedevelopmentofcoronarycollateralbloodvessels.
Themajorsupportforthisideahascomefromanexperiment
carriedoutbyDr.RichardW.EcksteinatWesternReserve

UniversitySchoolofMedicinein1957.(6)Thisexperimenton
dogs,nothumansinvolvedahighlyartificialsetof
circumstances.Bloodvesselswerecutandtiedtosimulatethe
obstructionandreducedbloodflowinatherosclerosis.Tubes,
reservoirsoffluidandmeasuringdeviceswereintroducedinto
thealteredarteriesorconnectedtothecirculatorysystem.The
dataindicated,accordingtoDr.Eckstein,thatarterialnarrowing
resultsincollateraldevelopmentproportionaltothedegreeof
narrowingthatmuchofhisinterpretationhasbeenverified
repeatedlybystudiesofanimalsandhumansunderlessartificial
conditions,andisnowwellacceptedand,second,that
exerciseleadstogreaterbloodflow.Thislatterconclusionhas
notonlynotbeenconfirmed,butanimpressiveamountof
scientificevidencecontradictsit.
Inanimportantstudyofwhetherexercisewouldincrease
coronarycollateralbloodflow,Dr.AndreNolewajkaandhis
colleaguesattheUniversityofWesternOntario,Canada,
studied20patientsfollowingaheartattack.(7)Randomly
assigning10ofthesubjectstoanexerciseprogramand10toa
controlnonexercisegroup,andusinghighlysophisticated
techniquestomeasurehowmuchbloodflowedthroughthe
heartmuscle,theyshowedthatbothgroupshadsimilarextent
andprogressionofcoronaryarterydisease,andthatneither
groupshowedchangesinthenetworkofcollateralbloodvessels
ortheamountofbloodflowingthroughtheheartmuscle.The
researchersconcludedthatexercisedoesnotaffectthe
progressionofcoronaryarterydisease,theamountofbloodflow
totheheartmuscleorthedevelopmentofcollateralblood
vessels.Anotherstudyoftheeffectsofexercisetraining,on16
menwithcoronaryarterydisease,reportedintheAmerican
JournalofCardiology,showedthatitfailedtohaveasignificant
effectonheartmusclebloodflow.(8)Angiographicstudies
(filmsofdyeinjectionsintothecoronaryarteries)bystillother
researchershavenotshownanyincreaseincoronarybloodflow
ineithertrainedathletesorasaresultofexerciseinordinary

peopleorpatientswithheartdisease.
Theconsensusofexpertsisthatthereisnoevidencethat
exercisetrainingincreasesthecoronarycollateralcirculationin
humans.Whencollateralcirculationimprovessubsequentto
training,itappearstobecoincidence.Theimprovementissolely
thebody'sresponsetoincreasinglynarrowedcoronaryarteries
asthediseaseprogresses,andhappenswithorwithoutthe
patientsomuchasliftingafinger.Theonlystimulusfornew
growthofcollateralcoronaryarteriesisseverecoronarydisease;
theonlywaytogrownewcoronarychannelsisforyourold
onestogetworse.Ifpreventiondoesn'twork,andcoronary
circulationisn'timproved,exerciseadvocatescanstillretreatto
thehighlypublicizedpositionthatexercisecanbenefityour
healthindirectlybycuttingdownonfactorsthatputyouatrisk
fordiseaseinthefirstplace.Scientists,againresortingto
technicalnomenclature,categorizeriskfactorsinto"primary"
and"secondary"ones.Primaryriskfactorsarethosewitha
clearcutandindependentstatisticalrelationshiptothe
developmentofcoronaryarterydisease.Inotherwords,the
presenceofanyoneoftheprimaryriskfactorsleadstothe
occurrenceofcoronaryheartdiseasemorefrequentlythanmere
chanceorcoincidencecouldexplain.Primaryriskfactorsare
highbloodpressure(hypertension),highbloodcholesterollevel
(hypercholesterolemia)andcigarettesmoking.
Eachoftheprimaryriskfactorshasbeenshownunequivocally
toberelatedtothedevelopmentofcoronaryarterydisease.
Yourchancesofgettingthediseaseareabovetheaverageif
yourbloodpressureisover140/90,ifyouhavehighlevelsof
cholesterolorifyousmokecigarettes.Thehighertheblood
pressure,thehigherthecholesterollevelandthemoreyou
smoke,theprogressivelygreateraretherisks.Notonlydoes
eachriskfactorindependentlycontributetoyourchancesof
gettingcoronaryheartdisease,butalsotheyaresynergistic.
Theireffectsaremorethanjustadditive.Theriskofdeveloping

coronarydiseaseifyousmokealot,forexample,maybetwice
thatofanonsmoker;ifyouhavehypertension,too,therisks
maymorethanquadruple.Andifyourbloodcholesterollevelis
alsotoohigh,yourriskofgettingcoronarydiseasemaybenine
tofifteentimesthatofapersonwithnoneoftheseriskfactors.
Secondaryriskfactorsarethosewithamuchlesscertainand
lessindependentrelationshiptocoronarydisease.Theyinclude
obesity,diabetes,stress,abnormalelectrocardiograms,
socioeconomicstatusand,mostimportantforthepurposesof
ourdiscussion,physicalinactivity.Mostphysiciansacceptthe
voluminousdatarelatingheartdiseasetoprimaryriskfactors,
fornearlyeverystudythathasbeendonehasshownthesame
statisticalrelationshipbetweenthedevelopmentofcoronary
arterydiseaseandthepresenceofoneormoreoftheserisk
factors.Thesituationregardingthesecondaryriskfactorsisless
certain,fortheireffectsoncardiachealtharefarlessclear.The
secondaryriskfactorsarethereforeoften"weighted"rankedin
orderofapparentimportancebyphysiciansandresearchers.
Whenthisisdone,physicalinactivityalmostalwaysranks
amongtheleastimportant.
Scientistshavepointedoutthatphysicalinactivitydoesnot
necessarilyprecedetheformationoffattyobstructionsinthe
arteries,andmanystudieshavenotfoundphysicalinactivityto
beariskfactoratall.Forexample,Dr.RayH.Rosenman,a
Californiacardiologist,studied2,635federalemployees.(9)He
couldn'tfindanyriskfromphysicalinactivity.WhenDr.L.
Wilhelmsen,ofSweden,analyzedseveralriskfactorstogether,
hefoundthatinactivepeopleoftenhappentobethosewhocourt
dangerbybeingoverweightand/orsmokingtoomuch.(10)
Stayingputmaybeassociatedwithheartdisease,butitdoesn't
makeitresponsible.Whatthesmokingandeatingpeopledoas
theysitmaybemoredirectlyrelatedtoheartdiseasethanthe
sittingitself.

Themostencouragingviewoftheriskfactorthesisisthat,
becausebothprimaryandsecondaryrisksarelargelyunderour
control,weshouldbeabletoavoidheartattacksbyavoiding
someoftherisksthatarestatisticallyrelatedtoheartdisease.In
recentyearssomestudieshaveshownthatloweringblood
pressure,reducingbloodcholesterollevelsandeliminating
cigarettesmokingallleadtofewercoronaryattacksandless
deadlyones.Dr.JeremiahStamler,ofNorthwesternUniversity
MedicalSchool,suggeststhatwecanthanktheantismoking
campaignfor50percentofthedecreaseincardiovascular
mortalityintheUnitedStatesinthelast15or20years,the
moveawayfromhighcholesterolfoodsandotherwaysof
reducingcholesterolfor25percentandbettercontrolofhigh
bloodpressureforanother25percent.(11)Nevertheless,thereis
lessagreementthatapersoncanbeassuredoffewerandmilder
coronaryattacksbycontrollingriskfactorsthanthereis
consensusthattheriskfactors,whentheyarepresent,
predisposeapersontosufferingcoronaryevents.
Whenitcomestoexerciseasameansofreducingriskfactors,
thereislessagreementstill.Forherethedataareevenless
convincing.Thethesisthatexercisefavorablyaltersthemajor
coronaryheartdiseaseriskfactorsisfarfromproven.Studies
haveshownconflictingresults,andtheinterpretationofthedata
variesamongobservers.Nonetheless,thethesishasmany
proponents,anditissufficientreasonformanytohavejumped
ontheexercisebandwagon,ifnottohavejoinedthecrusade.
Sincethethesisislessstridentandlessdramaticthanthebelief
thatexercisedirectlyprolongslifeorenhancescardiovascular
health,itisperhapseasiertosubscribetothisriskfactor
argument.Theclaimsthatexercisemodifiesheartdisease
riskfactorsaremoremodestthantheclaimsthatexercise
directlyprolongslifeandpreventscoronaryattacks.Andyou
canbelieveintheriskfactorexercisetheorywithoutthesense
offervororsuspensionofreasonthatseemsnecessaryin

acceptingandpromotingmoredramaticclaims.Theriskfactor
thesisisamoretentativenotion,claimingonlybeneficial
alterationincertainbiologicalvariablesthat,indirectly,may
leadtolongerlifeandbetterhealth.Assuch,itiseasierfor
exerciseadvocatestoacceptanddefend.Butitsacceptanceand
defensecanleadtothesamemischiefanddangersasbeliefin
thedirect,magicalandlifeenhancingpropertiesofexercise.
Highbloodpressureisamajorriskfactorforcoronaryheart
disease(aswellasforstrokesandkidneyfailure).Dependingon
thecriteriaselectedtodefineelevatedbloodpressureandthere
isstillsomedisagreementamongphysiciansonthispointitis
estimatedthat30millionto60millionAmericanshave
hypertension.Therefore,majorpublichealtheffortshavebeen
undertakentofindhypertensivepeopleandtogettheminto
treatment.Thepercentageofhypertensivesundertherapyhas
risensignificantly,andtherapeuticimprovementsinhighblood
pressureareamongthemajormedicaladvancesofrecentyears.
Inspiteofpragmaticadvances,wedon'tknowwhatusually
causeshypertension.Epidemiologicalstudiessuggestthatitis,
forsomepeople,relatedtohighsaltdietsandtoobesity,but
whenattemptstotreathighbloodpressurebydietaloneare
made,thepercentagehelpedisdiscouraginglysmall.Sincewe
don'tevenknowthemechanismsbywhichhypertension
develops,prescribingexerciseasawayofhaltingorreversing
thediseaseisnomorethanawildguess.Studiesseemtobear
outtheshotinthedarknatureofexerciseasatreatmentfor
hypertension.Althoughsomestudiesshowsmallreductionsin
bloodpressurethroughdynamicexerciseintreating
hypertension,theimprovementisminoratbest.Moreover,
expertsnotethatthelongtermeffectsofexerciseinpeoplewith
hypertensionareunknown,andtheyadvisecaution.Inastudy
of50competitivedistancerunners,"DistanceRunnersas
ModelsofOptimalHealth,"therewasasubstantialincidenceof
elevatedbloodpressure.(12)Fortypercenthadrestingblood

pressureofatleast130/85,whichledDr.HaroldElrick,director
oftheFoundationforOptimalHealthandLongevity,tosuggest
thatdaily,vigorousphysicalactivitydoesnotprotectpeople
fromhypertension.
Perhapsthebestperspectiveonthewholequestionofexercise
asameansofreducingbloodpressureisofferedbyDr.Marvin
Moser,ClinicalProfessorofMedicineatNewYorkMedical
CollegeandChairmanoftheJointNationalCommitteeon
Detection,EvaluationandTreatmentofHighBloodPressure.
(
13)Dr.Mosersaysthatcontrolledexercisecanberecommended
toimprovefitnessandtoaidinweightreduction,and"possibly,
toreducebloodpressureinasmallpercentageofpatients."But,
hesays,"therearenoconvincingdatathatsystematicexercise,
evenifperformedvigorously3to4timesaweek,hasresulted
insignificantcontinuousloweringofbloodpressure.
Thepreponderanceofmedicalevidenceandsentimentthus
seemstobethatclinicallysignificantreductionsinblood
pressurearenotachievedthroughexerciseevenwhen
performedvigorouslyanddiligently.Theremaybeafew
individualswithmildlyelevatedbloodpressureforwhom
successfulbloodpressuremanagementcanbeachievedthrough
anexerciseprogramcontrollingsuchmildlyhighpressure
maynotevenbenecessaryaccordingtorecentevidencebut
forthevastmajorityofthemillionsofhypertensivepeoplein
thiscountryandaroundtheworld,exercisesimplyisinadequate
andineffectiveasaprimarymeansoftreatment.Totheextent
thatelevatedbloodpressureisaprimaryriskfactorfor
developingheartdisease,exercisedoesn'thelp.
Whereasthesheernumbersofhypertensivepeopleandthe
relativeeaseofdetectingthemmakeelevatedbloodpressureof
perhapsprimeimportanceasacoronaryriskfactor,itisinthe
controloflipids(fats)particularlycholesterolandtriglycerides
thatexerciseisreportedtohaveitsgreatesteffect.Theexact

mechanismbywhichthesefattysubstancesinthebodyleadto
atherosclerosisisstilluncertain.Allwereallyknowsofaristhat
followingsomesortofinjurytotheinnerliningoftheartery
walls,fatsenterthewalloftheartery,becomeincorporatedinto
thecellsofthearterywallandeventuallyleadtothickeningof
thewallandnarrowingofthearterychannelthroughwhich
bloodflows.Whenthearteriesaresonarrowed,coronaryheart
diseaseistheresult.
Cholesterolandtriglyceridesdonottravelfreelyasfatsinthe
bloodstream,becausetheydon'tdissolveintheblood.Instead,
theyareattachedtocertainproteins;thecombinedmoleculesof
fatsandproteinsarecalled"lipoproteins."Therearemany
differentlipoproteins,andtheyvaryintheirdensityorweight.
Therearelowdensitylipoproteins(called"LDL"),verylow
densitylipoproteins(called"VLDL")andhighdensity
lipoproteins(called"HDL").Thefatintheverylowdensity
lipoproteinsislargelytriglyceride,whereasthelowdensity
lipoproteinsandthehighdensitylipoproteinscontainmostly
cholesterol.
Muchattentionhasbeenfocusedinrecentyearsonthe
differencesbetweenthevariouslipoproteinsastheyaffectthe
processofatherosclerosis.Researchhassuggested,butnot
proved,thatthelowdensitylipoproteinsandtheverylow
densitylipoproteinsdelivercholesterolandtriglyceridetoand
deposittheminthearterywalls,whilethehighdensity
lipoproteinsremovethefatsfromthearterywalls.Ifthis
eventuallyprovestobeso,lowdensitylipoproteinscouldbethe
majorvillainsthatcontributetoatherosclerosis,whilehigh
densitylipoproteinsmighttendtodiminishthebuildupof
obstructions.Somephysicians,basedontheworkdonesofar,
alreadyviewLDLandVLDLas"bad"lipoproteinsandHDLas
"good."
Theclinicalsupportforthisbeliefrestsonobservationsthat

peoplewithmoreHDLtendtohavelesscoronaryheartdisease,
whilethosewithmoreLDLandVLDLtendtohavemore
coronarydisease.ItisimaginedthatHDLcouldbeactingasa
chemicalscavenger,pickingupcholesterolfromthewallsofthe
bloodvesselsandtransportingittositesinthebodywhereitis
destroyedandexcreted.Whereassomescientistsconsiderthe
absolutelevelofHDLcholesteroltobeofmostimportancein
determiningwhetheratherosclerosiswilldevelop,other
researchersbelievethattheratioofHDLcholesterolto
LDLcholesterolis,infact,moresignificant.
ExerciseisclaimedbysometoincreaseyourlevelofHDL.If
thethesisthathighdensitylipoproteinsaregoodisvalid,then
anythingthatwouldraisethelevelofHDLshouldbeofvalue.
Unfortunately,theevidencethathighdensitylipoproteins
protectagainstcoronaryorothervasculardiseaseisnot
overwhelming,norhasitbeendefinitelyshownthatexercise
increasesamountsofHDL.
Whenhighdensitylipoproteincholesterollevelsareverylow,
theincidenceofcoronarydiseaseseemstobehigh.Whenthe
HDLcholesterollevelissomewhathigher,theincidenceof
coronarydiseaseislower.Butbeyondacertainlevelandnota
highoneatthattheprotectiveeffectofHDLseemsto
disappear,andtheriskofcoronarydiseaseseemstobe
independentofthelevelofHDLcholesterol.Ifyouhavevery
lowHDLcholesterollevels,thenalittlemoreseemstobe
better.Butifyouhaveevenamodestamount,morejustdoesn't
seemtohelpmuch.
Letusassumeforthemoment,however,thathighdensity
lipoproteinsaregoodsubstancesthathelptoclearcholesterol
fromthewallsofourarteriesandtherebycontributetoa
reductionintheriskofcoronaryarterydisease.Howstrongis
theevidencethatexercisesignificantlyincreasesHDLlevels?

OfthefewstudiesthathaveshownincreasesinHDLin
associationwithexercise,thoseincreaseshavegenerallybeenso
modestthatsobermindsmightdoubtthattheyhavebiological
significance.Inmanyinstances,theincreasesinHDLareeven
lessthantheerrorsinthemethodsofmeasurement.Insome
studies,levelsofverylowdensityandlowdensitylipoproteins
fellashighdensityonesrose,whereasinothersthelevelofonly
one,orneither,oftheselipidcontainingmoleculeschanged.In
yetotherstudies,where,insteadofmeasuringthelipoproteins,
cholesterolandtriglyceridelevelsthemselvesweremeasured,
therewereagainnoconsistentresults.Andtheamountof
exercisenecessarytocausechangesinthevariouslipidlevels
alsovaried.
AnumberofstudiesshownoriseinHDLlevelsdespitewell
controlledexerciseprograms.Twohundredtwentythreeheart
attacksurvivorsintheNationalExerciseandHeartDisease
Projectwererandomlyassignedtoanexerciseornonexercise
group,and,afteroneyear,therewerenochangesineithergroup
inanyofthelipidsmeasured.(14)ResearchersfromTulsa,
Oklahoma,reportedtotheAmericanCollegeofSports
Medicinethata12weekwalkjogprogramthatdidhavea
trainingeffectonthecardiovascularsystemofmiddleagedmen
didnotchangeanyoftheirlipids.(15)Moderatelytrained
runnersstudiedinColumbia,Missouri,(16)andhighlytrained
youngmenstudiedinSanJose,California,(17)similarlyshowed
nosystematicorsignificantchangesinfatsorlipoproteins.
Commentingonthesurprisinglyhightotalcholesterollevelsand
lowHDLlevelsinhighlyconditionedrunnershestudied,Dr.
HaroldElricksaidvigorousphysicalactivity"doesnot...
guaranteelowtotalcholesterolorhighHDLcholesterol
values....."(18)Finally,animportantcontrolledstudyof25men
and23womenfromtheUniversityofPittsburghSchoolof
Medicineshowedthat,despiteanexerciseprogramthat
increasedfitness,HDLcholesterollevelsdecreasedinthe
exercisers.(19)

Whenmeasurementslikethesearesovariableandinconsistent,
onewouldcertainlyhavetobeatruebelievertoclaimthatany
sensecouldbemadeofthem.Butlookingatsomeofthe
measurementsinthecontextofthosewhoweremeasured,one
canfindagleamofsense.
Inastudyof81healthysedentarymenrandomlyassignedto
runningorsedentarycontrolgroups,researchersnotedthatthose
whochosetorunmore,andactuallydidraisetheirHDLthe
most,startedoffwithhigherHDLlevels.(20)StudiesofHDL
levelsinexercisersmaywellbebiasedbyselfselection:people
whochoosetoexerciseoftenhavehigherlevelsofHDLtostart
with.
Despitethatgleamofsense,thewholesubjectofthe
relationshipbetweenexerciseandlipoproteinlevelsremains
obscure.Werebetterlighttoilluminatetherelationship,there
wouldstillbethetaxingquestionofwhetherelevatingHDL
levelsishelpfulanyway.
Aneditorialinthe1982NewEnglandJournalofMedicinenotes
thatnoonehasshownthatraisingHDLcholesterolreducesthe
riskofatherosclerosis.(21)AreporttotheInternationalCongress
onLipoproteinsandAtherosclerosisinSwitzerlandshoweda67
percentdecreaseincoronaryeventsasHDLlevelsfellin
responsetoanewmedication.Anditisnotablethatpatients
withararediseaseinwhichtheyhavenoHDLatalldon'tshow
earlysignsofcoronaryheartdisease.Allinall,itseemsclear
thatahighlevelofHDLsisn'tnecessarilyaharbingerofgood
thingstocome,alowleveldoesn'tautomaticallymeantrouble
andeffortstochangetheHDLlevelbyexercisearebyandlarge
pointless.
Inobservinganinitialgroupof260menfor25years,Ancel
Keys,oftheUniversityofMinnesota,notesnodifferencein
HDLlevelsamongthosewhodiedofcoronaryheartdiseaseand

thosewhosurvived.Keysconcludesthatthecurrententhusiasm
forHDLis"unwarranted,"andthatlowHDLcholesterolisnot
asignificantriskfactorfordeathfromcoronarydisease.(22)
Thethirdmajorcoronaryriskfactorcigarettesmokinghas
nodirectrelationshipwithexercise,butitsindirectrelationship
isanimportantone.Theincidenceofsmokingislessamong
runnersandexercisers.Whocanplayasetoftenniswhile
puffingaway,orhavethewindaftertwopacksadaytojogfour
miles?Moretothepoint,peoplewhochoosetoexercise
regularlyareoftencharacterizedbytheircommitmenttoa
wholelifestylepackagethatmaywellleadtobetterhealth.The
samemotivationthatmistakenlydrivesthemtopushforever
fasterspeedsandgreaterendurancecorrectlyleadsthemto
avoidcigarettesandpaycloserattentiontonutrition.EvenDr.
Bassler,whoseoriginalMarathonHypothesisislargely
responsibleforthemisguidednotionofrunners'immunityto
atherosclerosis,todaycreditsthelifestyleoftherunnerforthe
supposedbenefitsenjoyedbymarathoners.
Whiledoctorsandscientistsaregladtohavestatistical
relationshipsbetweenriskfactorsandcoronarydiseasefor
guidance,theywouldbehappierstilltounderstandtheexact
mechanismsofatherosclerosisandtheminutephysiological
eventsthatprecedethecuttingoffofbloodsupplytotheheart
muscle.Werethemedicalprofessiontohaveacompletepicture
ofthediseaseprocess,perhapsdowntothebiochemicallevel,
theninterventionatevensomeveryearlystagemightbe
possible.Indeed,thatpictureisbeginningtobesketchedout.
Hemostasis,thebiochemicalsystemofchecksandbalances
wherebytheconsistencyofbloodiscontrolled,hasalottodo
withtheminutedetailsofhowbloodbehaveswithinthe
coronaryarteries,andfaultyhemostasishasnowbeen
implicatedincoronarydisease.Asusual,however,
overenthusiasticexercisershavejumpedin,claimingthat
exercisehasabeneficialeffectonhemostasis.

Underordinarycircumstances,bloodisafluidthatflowseasily
throughtheveinsandarteries.Butshouldaninjuryoccura
cut,forexample,oraninternalinjurythesameblood
coagulatestostemtheflow.Coagulatedbloodabloodclotis
laterdissolved.Thesenecessarychangesinbloodarecontrolled
bytheenormouslycomplicatedbiochemicalsystemcalled
haemostasis.Althoughnotusuallyconsideredamongthemajor
coronaryriskfactors,alterationsinthehaemostaticsystemcan
haveacentralroleinvasculardiseaseingeneralandincoronary
diseaseinparticular.
Yourhaemostaticsystemiscomplicated.Aninjurytoablood
vesselsetsinmotionchemicalreactionsthat,likefalling
dominoes,takeplaceinsequenceuntilaclotforms.Once
formed,clotsdonotpersistforever.Anactiveanticlotting
system,alwaysatwork,dissolvesclotsoncetheyhaveformed.
Thereisaconstantinterplaygoingonwithinyourbodybetween
thebloodclottingandanticlottingsystems.Variousinternal
chemicalandmechanicalstimulitendtoactivateyourclotting
systemmuchofthetime,andifnotforyouranticlotting
chemistry,yourbloodwouldtendtocoagulateinmanyareasof
yourbody.
Evidencesuggeststhatmanypeoplewithvasculardiseasehave
anexaggeratedtendencytoformbloodclots.Clottingofblood
inthecoronaryarteriesisasingularlyimportanteventinthe
majorityofmajorheartattacks.Aclotusuallyoccursinan
alreadynarrowedportionofthecoronaryartery,andis
superimposedonacholesterollipidplaqueinthearterywall.
Manysuchclots,composedofvariouscellsfromthe
bloodstreamheldinaframeworkofproteinstrandscalled
"fibrin,"arelargeenoughtobeeasilyvisible,butthisisn't
alwaysthecase.
Insomeinstanceswhereheartattackshaveoccurred,yetnoclot
canbefound,tinyclotscalled"microthrombi"arethelikely

culprits.Invisibletothenakedeye,theyalsotendtohave
becomedissolvedbythetimearesearchercancheckfortheir
presence.Microthrombiarecomposedlargelyofplatelets,cells
travellinginthebloodstreamthatareresponsibleforplugging
upinjuriestobloodvesselwalls.Plateletsnotonlyactas
physicalplugsbutalsoreleasechemicalsthattriggertheprocess
oflargerclotformation.Althoughyoumaybeawareofsuch
"responsetoinjury"goingsononlywhenyouscrapeyourknee
orstubyourtoe,platelets,bloodvesselwalls,clottingfactors
andtheanticlottingsystemsallinteractwithoneanotherina
dynamicandongoingprocesswithinyourbodyallthetime.
Itbeginstolookasthoughatherosclerosisrepresentsjustsucha
responsetoinjury.Theinnerliningofarteriescanbeinjuredby
manythings,includingchemicalsubstancessuchasfat
moleculestravellingintheblood,bodyhormoneslike
adrenalineandothernaturalchemicalsubstancesinthebody.
Outsidechemicalslikenicotineandcarbonmonoxidearealso
potentiallyinjurious.(It'sinteresting,inthisregard,thaturban
joggersmayhavebloodlevelsofcarbonmonoxideequivalentto
thoseofchronicsmokers,buttheygettheirsfromsucking
trafficpollutedairintotheirpantinglungs.)
Thearteryliningmayalsobeinjuredbymechanicalforces,such
astheshearforcesoftheblooditself.Bothrisesandfallsin
shearforceagainstthewallofthearteryhavebeenimplicated.
Sometimesthesimpletraumaofbloodcellsbumpingagainstthe
innerliningofthebloodvesselmayproduceinjury.These
traumatizedcellsmaythenreleasechemicalsthatfurtherthe
damage.
Anyinjurytotheinnerliningofanarterycausesplateletsto
sticktothesiteoftheinjury.There,theplateletsrelease
moleculesthatstimulatecellsdeeperinthearterywallto
multiplyandtomigratetotheinnersurfaceoftheartery,
causingittothicken.Cholesterolandotherlipidscarriedinthe

bloodstreamarethendepositedinthisthickened,injuredarea.
Asthisprocessinjurytothearterylining,stickingofplatelets,
thickeningofthelininganddepositingoffatsoccurs
repeatedly,thechannelinthearteryforbloodflowis
progressivelynarrowed.Finally,plateletsnotonlysticktothe
injuredinnersurfaceoftheartery,buttheyformclumps,which
releasestillotherchemicalsthatleadtothemassofcoagulated
bloodcalledaclot.Atthispoint,ifnotearlier,whenplatelets
haveformedonlymicrothrombi,aheartattackislikely.
Someclaimthatexerciseaffectsthehaemostaticprocessby
tiltingthebalanceawayfromclottingandtowardthedissolving
ofclots,achangethatcouldbeviewedasfavourable,atleastby
potentialvictimsofcoronaryarterydisease.Iftheclaimwere
firmlysupportedbyscientificevidence,itcouldbeareasonable
justificationforjumpingintosneakersandsweatpants.The
evidence,however,isfarfromconvincingandevensuggests
thatexercisemaysometimestilthaemostasistheotherway,
towardclottingratherthananticlotting.
Inonestudy,clumpingtogetherofplateletsstimulatedby
adrenalinedecreasedinasmallnumberofexercisingmen,but,
inspiteofthefactthatonlytheexerciseaspectoftheprogram
waswellpublicized,theirregimenalsoincludeddietary
modificationandabstinencefromsmoking,sobenefitscan't
fairlybeattributedtoexercisealone.(23)Theauthorsofthe
studythemselvescommentedthatthebiologicalsignificanceof
whattheyobservedwasunclear.Inotherstudies,platelet
clumpingincreasedafterexercise.(24)
Andsoitgoes.Thethirtyfiveorfortystudiespublishedin
majorjournalsontheeffectsofexercisealoneonplatelet
clumpingoneofthebigstepsinformingclotshavefound
variableresults:somefoundanincrease,someadecreaseand
othersnoeffectatall.

Thedegreetowhichtheplateletstendtoclumpmaybe
uncertain,buttheabsolutenumbersofplateletsdogoupwith
exercise.Almostallstudiesofplateletnumberfollowing
strenuousexerciseshowincreasesintheplateletcount,the
actualnumberof.plateletsintheblood.Dr.H.S.S.Sarajas,of
Helsinki,Finland,foundthatplateletsincreasetoasmuchas
twicetheirbaselinenumberafterbothshortterm(30minute)
runningandlongterm(marathon)runningandprolongedbrisk
marches.(25)Plateletclumpingactivityalsoincreases.Ifthe
studiesthatshowincreasedclumpingafterexerciseareaccurate,
andthereisanabsoluteriseinplateletnumbers,andthoselarger
numbersofclumpingplateletsalsoinducemoreactiveclotting,
exercisebeginstolookdownrightdangerousfromahemostatic
pointofview.
However,itistheiffinessofallthisworkonhaemostasisthat
standsoutmoreclearlythananyconclusionswhenallthe
studiesareexamined.Twomoreexamplesconvincinglyshow
thattheresimplyisn'tmuchtobesaidonewayortheother
abouttheeffectsofexerciseoncontrolofbloodconsistency.In
a1981studyonbloodviscosity,orthickness,researchersat
CornellUniversityandColumbiaUniversityfoundthat
sedentarypeoplehaveveryslightlythickerblood(about4
percent)atrestthandotrainedrunners.(26)Thickerblood
doesn'tflowsoeasily,anditisknownthatpooledbloodblood
thatisn'tflowingatalltendstoclot.Butafterexerciserunners
hadincreasesof5percentandnonrunnersincreasesof4
percent,leavingamere3percentdifferenceinbloodthickness
betweenrunnersandnonrunnersasgroups.
Inasecondexampleofbafflingresults,scientistsatDuke
Universityreportedthatphysicalconditioningenhancedthe
body'sabilitytodissolvebloodclotsundertheartificial
circumstanceofhavingatourniquetaroundthearm;theyalso
found,butdidn'temphasize,thatunderordinaryresting
conditionstheabilitytodissolveclotsapparentlydecreased.(27)

Ifanexerciseproducedincreaseinclotdissolvingabilityisa
benefit,thenthedecreaseatrestafterpeoplehaveexercised
mustbeadisadvantage.Sincemostofusevenexercisers
spendmoretimeatrestthanwedowithatourniquetaroundour
arm,theresultsaren'tencouragingforexercisers.Withthe
interplayofclottingandanticlottingactivitygoingoninusat
alltimes,anything,exerciseincluded,thatdiminishesouranti
clottingforcesseemstopresentapotentialrisk.
Exercisershaveexpectedthattheirintuitivesenseofgaining
vigorfromagoodsessionofhandballor20lapsinthepool
wouldactuallyshowupthroughthemeasuringinstrumentsand
underthemicroscopesofscience.Thereshouldbereal
physiologicalchanges,notonlyinstaminaandbrawn,butalso
deepinside,attheveryheartofthematter.Thisgiftsciencehas
beenunabletogivethem.Thewholescientificcommunity,
cardiologistslikemyselfespecially,wouldliketopromisethat
exerciseremovesthefattyobstructionsfromarterywalls,
reducesthepressureofbloodagainstthem,keepsthejuices
flowing.Butwecan't.Theresimplyisnoevidencetosupport
thosehopes.Asfaraspreventionofatherosclerosisorprotection
fromitsconsequencesisconcerned,exercisewillgetyou
nowhere.
Thereisstillanotherpromise,widelyofferedandsopowerful
thatitcompelssomepeopletorunwhentheywanttowalk,to
pushaheadwhentheylongtorest,eventodrivethemselves
beyondthecommonlimitsofpainandexhaustion.Thatpromise
isthatphysicalexertionleadstopsychological,emotionaland
spiritualbenefitsaswellasphysicalones.
Physicalfitnesscanmakeyoufeelbetter.Butdoesitsooththe
nervesandcuredepression?Doesitleadtogreaterself
awareness?Isthereamagicalunionofbody,mindandsoul?
Canyouruninaspirituallyusefulquest?

The Exercise Myth by Dr H Solomon

6. The Magic Runner

Exercisehasbeencreditedwithawidevarietyofpsychological
benefits,fromplainold"feelinggood"toeuphoriathatverges
onthemystical.Sincetheseeffectsareinherentlysubjective
theydefyeasymeasurement.Howdoyoumeasuretheamount
of"good"apersonfeels?Andwhenyoucanpsychological
testingdoesseemtomeasuresomethingyoucan'tsayforsure
wherethegoodnesshascomefrom.
Nevertheless,thesimplegoodfeelingthatcomeswithalittle
sweatissowellknowntomostofusastobeunarguable.Ifeel
goodafterasetoftennis,andmybeertastesbetterafteran
afternoonwalkonthebeach.Maybepullingweedsdoesthatfor
you,ormaybeittakesatwomilerun.Whateverkindoramount
ofeffortittakes,workingforawhilealittleclosertoyour
physicalcapacityusuallybringsacertainpleasure.
Buteventhislowestlevelofemotionalbenefitisn'tuniversal.
Therearethosewhoabhoradropofperspirationanddon'tfeel
theleastcomfortinbeingpushedtoexercise.Theirdegreeof
pleasuredoesn'tparalleltheirbodies'oxygenconsumption;
exerciseforthemisa"downer."Theymaygetthesame
comfortableandpleasantfeelingsothersgetfromexerciseby
readingagoodbookorcraftilycheckmatinganopponentinthe
coolrecessesofachessclub.
There'snothingwrongwiththeexperienceofthosewhohateto
exercise,andthere'snothinginherentlyrightaboutthe
experienceofthosewholoveto.Simpleexperience,foreachof
us,simplyiswhatitis.Toassumethatallpeoplewillget

pleasurefromwhatpleasesyouisasfoolishasassumingyour
childrenwilleattheirspinachbecauseyouhappentoloveit.
Yourdelightandtheirdistasteareequallyvalid,andequally
unarguable.
Atthenextlevel,however,exercisersclaimtherapeuticbenefits,
suchasrelieffromanxietyanddepression.Herethepromises
becomequestionable,andtheneedforobjectivestandards
becomesmoreevident.Ifapersoninemotionaldistressis
misledbybaselesspromises,thatisacrueltythatshouldbe
stopped;ifthebenefitsarereal,exerciseisamostappealing
therapy.
Theideathatphysicalexerciseconfersavarietyoftherapeutic
benefitsisneithernewnoroutlandish.Anumberofexperiments
andstudiescarriedoutoverthepastseveralyearshavereported
exerciseassociatedimprovementsinintellectual,emotionaland
socialareas,especiallyinpeoplejudgedtobesuffering
psychologicaldistress.Andthesubpopulationsofchronically
anxiousordepressedpeopleareamajormentalhealthproblem.
Mostinvestigationhasconcentratedonthequestionofwhether
physicalexercisemightalleviatedepressionandanxiety.
Psychologicaltestinghasestablishedsomemeasuresofthese
subjectivestates.Thereareproblems,though,inevaluatingsuch
studiesanddrawingconclusionsthatcanbeappliedacrossthe
boardtothepopulationingeneral.
First,thereisdisagreementonwhatconstitutesa
psychologicallyhealthyindividual.
Thedaymaycomewhenwecanbiochemicallyassessthehuge
varietyofhormonesandbraintransmittermoleculesthat
ultimatelycontroloursubjectivefeelings,analyzetheir
interactionsandcomeupwithanobjectivemeasureofjusthow
goodorbadapersonfeels.Thatdayisstillbeyondthehorizon.
Meanwhile,researchersandtherapistsmustrelyonwhatare

called"subjectivetests,"which,byelicitingaperson'sreactions
toneutralstimuli,suchasblandpicturesormeaninglessshapes,
orbyanalyzingaperson'sresponsesinhypotheticalsituations,
allowthetestertogaugehowcheerfullyorgloomily,withwhat
calmnessorfear,apersonviewslife.Howwellthesetests
matchhowthepersonperceiveshimselffeelingandwhether
theyaccuratelypredictwhatatherapistwillfindduringthe
deeperprobingoftreatmentareuncertain.
Besidestestsforanxietyanddepression,therearealsoself
reportingtechniquesforgaugingsuchrelatedaspectsasself
esteemandsocialoutgoingness.Theresultsofthetwosortsof
testsgenerallyjibewell:apersonwhoisjudgeddepressedby
subjectivetestingreportsevidenceoflowselfesteemand
clinicalsymptomsofdepression,suchassleeplessness,poor
appetiteandfatigue.
Inaway,thiscorrespondencebetweenvarioustestresults
createsproblemsinevaluatingtheeffectofanysingletypeof
treatment.Ifaperson'sdepressionliftsaftertreatment,didthe
therapyworkdirectlyonhisdepression,ordiditworkby
improvingselfesteem,byofferingsocialsupportorbyhelping
himtosleepbetter?Theproblemofinterpretationisparticularly
difficultwithexercisebecauseithasprovedimpossibleto
isolateexertionitselffromthemanyothercomponentsofa
therapeuticexerciseprogram.
Also,althoughstandardizedpsychologicalandpsychiatric
criteriaforanxietyanddepressionexist,it'shardtorelateour
ownnormaleverydayconcernstopathologicalstates.Thesame
measurableamountofanxietythatparalyzesoneindividual
mightleadanothertogetoutthereanddosomethingaboutit.
Oneofusmightbeimmobilizedbythequantifiablysame
depressionthatanotherofuscopeswithwell.Indeed,anxiety
thatwecanidentifyasarisingfromacausethatothers,too,find
reasonablelosingajoborhavingadesperatelyillchildmay

bethehealthyresponsetoemergencythatmovesustohandle
thesituationasbestwecan,justasdepressionafterthedeathof
someonewelovemaybethehealthywithdrawalthatallowsus
eventuallytoreorganizeourpsychesinternally,andtorecover.
If"freefloating"anxietyforwhichwecanfindnoexternal
causeordepressionbeyondwhatrealityseemstoexplaincanbe
successfullytreatedbyanytherapy,wehavenowayofknowing
whetherthesametreatmentwouldworkfornormalfearsand
sadness.Andperhaps,becausethesenormalresponsesmaybe
necessaryones,weshouldn'ttrytotreatthem.Thecomplexity
ofpsychologicalissuesmakesmeasurement,interpretationand
evaluationalottrickierthancountingplatelets.Weshould
regard"objective"studiesintheseareaswithsomeskepticism.
Almostallstudiesofexerciseastherapyshowsomeeffecton
depression.ACaliforniastudyofdepressioninjuniorcollege
studentsinasemesterlongjoggingcourseshowedthat,while
bothmenandwomenimprovedtheirphysicalfitnessas
expected,onlythewomen,evaluatedbytestingasmore
depressedattheoutset,improvedtheirpsychologicalfitness.(1)
Analyzingthedata,thestudyauthorsconcludedthatthoseinthe
poorestphysicalandpsychologicalconditionatthestart
improvedthemost,bothphysicallyandpsychologically.This
unsurprisingconclusionseemsmerelytorestatetheobvious:the
loweryouare,themoreroomthereistomoveup,andthemore
youimprove,thebetteryoufeelaboutit.
Theideathatexerciseperhapsalleviatesdepressionbestinthose
mostseverelydepressedtobeginwithhasbeensuggestedby
otherstudiesaswell.Inagroupof58beginninglevelrunners
whoranforaselfchosennumberofhoursoveratenweek
period,themostsignificantimprovementin"depressionscores"
wasbythemostseverelydepressedsubjects.(2)Sincethe
subjectsthemselveschosehowmuchtorun,important
personalitydifferencescouldwellhaveconfoundedresults
attributedpurelytoexercise.

Inanotherstudyofuniversitystudents,bothnormaland
depressedsubjectsshowedlessdepressionfollowingatenweek
joggingprogram.Again,thosewhojoggedthemostshowedthe
greatestimprovementandalsowerethemostdepressedinthe
firstplace;theyhadthemselveschosenthemostvigorous
exercise.Becausetheinvestigatorsdidnotconcealthatthe
purposeoftheirstudywastomeasuretheeffectofexerciseon
depression,theauthorsofthestudythemselvessuggestthat"the
subjects'choicesmayreflecttheircomplianceortheir
desperation."(3)
Theresultsofanystudyofpsychologicalvariablestendtobe
influencedbythepsychologicalmakeupofthesubjectsand
theirexpectationsoftheoutcomeoftheexperiment.Asubject's
pleasureinphysicalexertionorexpectationofbenefitsmay
enhancehisabilitytogetbetter,justashisdistasteforexercise
orhisskepticismaboutitsbenefitscanobviateanytherapeutic
effect.Beliefthatatreatmentwillhelpmakesithelpful,evenif
thetreatmentisasugarpilloranonsenseincantation.Thisfact
hasbeenwellknowntoscienceforcenturies,andhasbeen
namedthe"placebo"effectfromtheLatinfor"Iwillplease."
Theplaceboeffectisnotimagination,butabiological
phenomenon;althoughitsmechanismshavenotyetbeen
elucidated,scientistshavelittledoubtthatmeasurable
biochemicalchangesarebroughtaboutthroughtheintangibles
ofhope,beliefandthekindministrationsofotherswithor
withouttheaddedallureofadummypill.Theeffectis,infact,
sopowerfulthatthesedaysnotrialsofnewmedicationsare
credibletodoctorsunlesstheyincorporate"doubleblind"
methodology,inwhichneithersubjectsnorexperimentersknow
whoisgettingthemedicationandwhoitsdummycounterpart.
Onlyinthatwaycanresearchersdiscernwhetheranewdrug
hasaneffectbeyondtheplaceboeffect.
Doubleblindstudiesoftheeffectsofexerciseondepression

aren'tpossiblethereisno"fake"versionofexercise,orany
wayforeitherexperimentersorsubjectstobeblindtoit.
Therefore,everystudydoneistaintedbytheplaceboeffect,and
soisthesubjectiveexperienceofnormalpeoplewhodosetheir
illswithexercise.
Ifyou'rerepeatedlytoldbyfriends,family,professionalsandthe
mediathatexercisewillupliftyouandprovideemotional
"highs,"beliefmaybesufficienttomakeithappen.Itisquite
possiblethatantidepressanteffectsfollowingtherapeutic
exerciseprogramsarelargelyduetotheexpressedandimplied
hopesoftheexperimenters,aswellastotheexpectationsof
theirsubjects.Indeed,inonestudyofexerciseaspsychotherapy
fordepression,thetherapistweightedthescalesblatantlyby
joggingwithhispatients.
Furthermore,ifyou'retoldthatacourseofactionwillhavea
certainresult,andyouinvesttime,energyandmoneyin
carryingitout,youarenoteasilydisposedtoadmittingthatyou
didnotachievetheresult.Youmayevenfeelfoolishandhavea
naggingsensethatyoumightbelackinginsomethingifyou
don'tfeelwhatothersdo.Fewarereadytoadmit,eitherpublicly
amongtheiracquaintancesorprivatelyonsomepsychologist's
selfreportform,thatperhapstheyshouldhaveboughtabook
insteadofsneakers.
Whenpeopleareopenlyunenthusiasticaboutphysicalexertion
andwhentheirskepticismaboutitsbenefitsishigh,exercise
doesn'tworksowell.Inoneanalysisofanexercisestudy,for
example,thedropoutratewasveryclearlyaffectedbythe
patients'feelingstowardtheexercisesessions.(4)Thosewhodid
nothaveastrongbeliefinthebenefitsofexerciseshowedthe
highestdropoutrate.Theoneswhodroppedoutsoonestwere
notonlytheleastenthusiasticaboutexerciseinthefirstplace,
butalsoexperiencedfatigueandperceivedlittleorno
psychologicalbenefit.Asinotherstudies,thosewhowere

enthusiasticalsocompliedthebestwithwhatexperimenters
wishedofthem,andtheybenefitedthemost.
Thesameholdstrueforexerciseasitrelatestoanxiety,the
othermajorpsychologicaldiscomfortforwhichexercisehas
beencreditedwithbenefits.Expectationsandperceptions
mediateaperson'sresponsetoanygiveneffort.Inone
investigation,theplaceboeffectwasincorporated,thoughina
differentwayfromdoubleblindtrials.Anumberofadultmales
wererandomlyassignedtooneofthreegroups:astandard
exerciseprotocolofendurancerunning;thesameexerciseafter
swallowingaplacebopillparticipantsweretoldwouldreduce
thefatigueanddiscomfortofexercise;thesameexerciseafter
performinganinnocuousrelaxationexercisewiththesame
assurancethatitwouldreducefatigueanddiscomfort.(5)After
vigorousexercise,thereisusuallyatransientincreasein
anxiety.Whenthisexpectedriseinanxietywasmeasured,the
usualresponsewasattenuatedintheplacebopillandplacebo
relaxationgroupsbytheexpectationthattheywouldfeelbetter,
althoughmeasuredcardiovascularandhormonalresponsesto
thestandardexercisewerethesameforallgroups.
AsmallbutverywellcontrolledstudybyDr.DanEpstein
dividedsubjectsintothosewhowerenewlytoparticipateinan
exercisegroup,thosewhoweretoparticipateinafamiliarbut
sedentaryactivityandthosewhoweretotakeupasimilarly
quietactivitybutonethatwasnewtotheparticipants.(6)The
purposeofthisratherelaboratedesignwastotakeintoaccount
thepossiblepsychologicaleffectsofsimplystartinganew
activity,beitexerciseorsomethingelse.AlthoughDr.Epstein
expectedthatsubjectsintheexercisegroupwouldshow
significantdecreasesindepressionandanxiety,aswellas
increasesinbodyandselfsatisfactioncomparedwiththeother
groups,hishypothesiswaswrong.Exercisersshowedno
significantdecreasesindepressionoranxiety,orincreasesin
bodyorselfsatisfactioncomparedwiththeothergroups;

indeed,allreactedsimilarly,showingnoparticularchangein
anyofthepsychologicalvariablesmeasured.
Whereassomestudieshaveshownexerciserelatedreductionsin
anxiety,othershavenot.Dr.FerrisN.Pitts,ofWashington
UniversitySchoolofMedicineinSt.Louis,hasevensuggested
thatexercisecaninduceanxiety,bothinneuroticandalready
anxioussubjectsandinnormalpeople.(7)Dr.Pittsshowedthat
lacticacid,whichaccumulatesinthebodyduringexertion,and
adrenalineanditsrelatedcompounds,whichincreaseduring
exercise,caninduceanxietysymptomsinneuroticallyanxious
individualsandinnormalpeopleunderstress.Furthermore,
sincesymptomsproducedbyanxietyandphysicalexertionare
similarapoundingheartandbreathlessness,forexample
Dr.Pittssuggestedthatexercisecouldintensifysuchreactions.
Anecdotalevidencesuggeststhatformanypeopleeveryday
formsofactivitymayatleasttemporarilyrelievethejitters.
Expectantfatherspace,apprehensivechildrenmayfairlyburst
intophysicalactivityandalmostnoonefeelingunusually
nervouscanjustsitstill.Thismaybebecausefearresponses
mediatedthroughthehormonesoftheadrenalglandreadythe
bodyphysiologicallytomeetexternalchallengesbyfightingor
fleeingdanger.Itstandstoreasonthatifwerespondtothe
warningof"butterfliesinthestomach"asourbodyis
"supposed"tobydoingsomethingwewillfeelbetter.
Certainlysomeofusdofeellessanxiousaftersplittingapileof
logsorplungingthoughthesurf.Butifthesesurgesofexertion
bringimmediateshorttermrelief,doesthatmeanaroutineof
exercisecanhaveaneffectonchronicanxietyoverthelong
term?
Manystudiesofexerciseandalterationsinmoodinvolve
relativelyfewpeopleobservedforratherbriefperiodsoftime,
methodologicalproblemsthatrenderconclusionshardtoapply
tothemultitudethathastakenupexerciseasawayoflife.Ina

studybytheNationalExerciseandHeartDiseaseProject,these
problemswereeliminatedbyusingalargesampleandstudying
thesubjectsoveralongperiodoftime.Thestudywasalso
valuableinthatitaddresseditselftopsychosocialhealthin
general,includingdepression,anxiety,hysteria,nervousnessand
sexualactivity.Thestudygroupwas651malesurvivorsofa
heartattack,andthesesubjectswereevaluatedbeforeexercise
andat6months,1yearand2yearsafterexercisebegan.The
results,publishedintheArchivesofInternalMedicinein1982,
wereclear:"Thisstudyindicatesthatvolunteers...inan
exerciseprogramforatwoyearperioddonotachievegreater
psychosocialbenefitthandocontrolsubjects."(8)
Sincetherearecontradictoryclaimsofpsychologicalbenefit
fromexercise,weneedsomeperspective.Weareprobablywise
toconcedethatsomepeoplewhotryexerciseasatherapyfor
depressionoranxietyarehelped,althoughthatisafarcryfrom
theideathatexerciseispsychologicallyupliftingforall.Butthe
pointisnotsomuchwhetherexerciseworks,but,rather,thatit
hasnospecialpropertytorecommendit.Themixedresultsof
studies,infact,seemtoindicatethatexerciseaffectsmoodand
psychologicalstatebymeansthathavenothingtodo
specificallywiththephysiologicaleffectsofexertion.The
importantandunansweredquestionis:Wouldn'tanythingelse
otherthanaprogramofjogging,aerobicdancingorother
workoutsaccomplishasmuch?
Whenpeoplehaveenteredexercisestudies,theyhavealmost
alwaysenteredasocialsituation.Theymayhavebeenstudents
whonowruntogether,patientswhonowjointogetherina
therapeuticenterprise.Themeresocialinteractionthebanter
andchatteramongsubjects,theconcernfortheirwellbeingby
theresearchers,theexchangeofopinionsandprogressmust
liftthespirits.Isolationistheenemyofthedepressedandthe
anxious.Givesuchpeopleagrouptobelongtoandfellowswith
whomtounburdenworries,andsomereliefisboundtooccur.

Suchreliefalsocomes,however,bysingingwithachurchchoir,
orbygoingfishingwith"theboys,"orbydoingvolunteerwork
inone'scommunity.Exercise,ifenjoyedwithinagroup,hasthe
advantagesofsomeconviviality,butithasnomonopolyon
socialrewards.Socialaspectswereratedhighlyinasurveyof
factorsinfluencingresponsestosupervisedexerciseprograms.
InaninterestingstudyinPublicHealthReports,Dr.Fred
HeinzelmannandRichardW.Bagleyexaminedsuchfactors.(9)
Atthebeginningoftheprograms,desiretofeelbetterand
healthierandconcernsaboutreducingthechancesofaheart
attackweretheprimarymotivationsforpeopletojoin.The
socialaspectswereratedasleastimportant.Incontrast,asurvey
oftheparticipantsattheendoftheexerciseprogramsindicated
thatthesocialaspectswereamongthebestlikedfeaturesandan
importantreasonforpeoplechoosingtostayintheprograms.
Asenseofmasterythecompletionofatask,the
accomplishmentofafeatorthelearningofavaluedskillthat
onceseemeddifficultorimpossiblemayalsoexplainsome
salutaryeffectsofexercise.Suchfeelingsofmasteryare
commonlyreportedasphysicalfitnessleadstogreaterphysical
performance.Moreover,asexercisersbecomemorefittheyare
likelytoviewthemselvesalbeitincorrectly,aswehaveseen
aslessvulnerabletoheartdiseaseanddeath.Justaspeoplewho
aredepressedfeelallsortsofachesandpains,thosewhobelieve
themselvestobeinthepinkofhealthfeelcheered.Iwouldn't
fortheworldputdownstrongbacksandnimblefeetasan
avenuetofeelingemotionallystrongandflexibleaswell,but
thiswayisn'teveryone'sway.Whynotthemasteryofadegree
insocialwork,thenimblefingersofaknitterandthesturdy
backofthetroutfisherman?Thereareasmanywaystofeelat
thepeakofone'spowersastherearepeople.
Exercisemayalsosimplybeadiversion,atimeoutfrom
worriesandresponsibility.Howdeeplycanyouworryabout
yourworkwhenyou'reworriedaboutgettingyournextbreath?

Canyouthinkquiteasmuchaboutthekidswhenyou'renotsure
you'llevergetoverthenexthill?Diversionarytimeoutfrom
ordinaryconcerns,notexercisespecifically,iscreditedwith
psychologicalbenefitsbyresearcherswhohavefoundsimple
quietrest,vigorousexerciseandmeditationallequallyeffective
inreducinganxiety.You'llhearthesamefromstampcollectors,
pottersandweekendcarpenters.
Whilesocialinteraction,masteryandsimplediversionmay
explainmanyofthereportedpsychologicalbenefitsofphysical
activity,theveryrecentdiscoveryofintriguingchangesinbody
chemistryaccompanyingvigorousexertionhasrefocused
attentiononthephysiologyofexercise.Untillateinthelast
decade,whatlittleweknewaboutsubjectiveemotionalstates,
suchasfearoraggressiveness,wasthoughttobemediatedby
hormonesyouorIreadaboutsometimeagoinhighschool
textbooksadrenaline,testosteroneandsoon.These
hormones,whichcirculatefreelyintheblood,haveverygeneral
effectsandactonorgansandtissuesthroughoutthebody.How
theymightberelatedtoresponsesmoresubtlethanthereddened
faceofangerorthepalpitationsofpanictothepleasuresof
nostalgia,forexample,orthestimulationofdiscussion
remainedamystery.Lackinganobviousbridgebetweenthe
finerpointsofmentallifeandgrossphysicalmanifestations,it
remainedacceptabletodistinguishbetween"mind"and"body."
Mindwassomethingthattranscendedphysiologyor
biochemistry,andwasthereforenotsubjecttothequantitative
methodsofscience,whoseprovincewasthebody.
Beginninginthe1970s,researchersisolatedawholenewgroup
ofsubstances,whichtheysoonrealizedmightmediateallsorts
ofactivityamongnervecellsinthebrain,includingthosethat
controlpleasureorthelackofit,clarityofthoughtorconfusion,
steadinessofmoodorunnervingfluctuation.Mindandbody
thusbegantocometogetherweareourbiochemistryinspirit
aswellasintheflesh.

Amongthefirstandmostfascinatingoftheseneurotransmitters
tobediscoveredweretheendorphins,opiatelikemolecules
producedwithinthebrainthathaveeffectssimilartomorphine
onthecentralnervoussystem.Althoughlittleofthedata
accumulatedsofarhavebeenconfirmed,endorphinshavebeen
creditedwithshuttingoffawarenessofpaininpeoplewhohave
beengrievouslywounded,havebeenlinkedtothepainreliefof
acupunctureand,somesuspect,mayexplainthefeelingofwell
beingthattypifiessomeplaceboeffects.Needlesstosay,when
itwasdiscoveredthatbloodlevelsofendorphinsrisewith
exercise,thereseemedatlasttobeamechanismbywhich
exertioncouldcausepleasure,ifnoteuphoria.
Thefactthatendorphinlevelsinthebloodrisewithexercise,
however,doesn'tdemonstratethattheyarethecauseofany
changeinemotionalstate.Dr.PeterFarrell,oftheUniversityof
Wisconsin,emphasizesthatemotionaleffectsofexercise,if
thereareany,occurinthebrain,butthehumandataon
endorphinsdealwithlevelsinthebloodstream.(10)Wejustdon't
knowwhetherthelevelofcirculatingneurotransmittersreflects
thelevelwithinthebrain.Also,torespondtoneurotransmitters,
braincellsmustbeequippedwiththeproperreceptor,towhich
thetransmittermoleculecanattach.Peoplevaryconsiderablyin
boththequantitiesofendorphinstheymanufactureandthe
populationofreceptorsthatwillacceptthem.And,finally,
people'sabilitytoproducemoreendorphinsinresponsetothe
stressofexercisealsovaries.
Dr.WilliamP.Morgan,oftheSportsPsychologyLaboratoryat
theUniversityofWisconsin,saysthatthereissuchtremendous
variabilityinendorphinlevelsamongdifferentindividualsboth
beforeandaftertheyexercisethatitishardtoseethat
neurotransmitterasthecauseofaspecificcentralnervous
systemeffect.(11)Asa1980reviewofthesubjectstated,littleis
knownaboutthephysiologicfunctionsofendorphinsandtheir
clinicalimplicationsarenotwellunderstood.(12)

Perhapsmosttellingisarecentstudyreportedfromthe
UniversityofHawaii.(13)Agroupofmarathonersunderwent
psychologicaltestingbeforeandafterrunningforaminimumof
onehour.Theyweregivenaninjectionofeitheraplaceboora
drugknowntoblocktheeffectsofendorphins.Therewereno
differencesinthemoodchangesassociatedwithrunning.The
drugandtheplaceboactedsimilarly,indicatingthatalthough
moodchangesassociatedwithrunningmaybereal,theyarenot
mediatedbyendorphins.
Nevertheless,thediscoveryofendorphinshaslentsome
credibilitytotheultimateexpressionofexerciseinduced
alterationsinpsychologicalstatestheeuphoriathathas
becomeknownasthe"runner'shigh."Wedoknowthat
morphine,sosimilarinstructuretoanendorphinthatitfitsinto
thesamereceptor,mayproduceeuphoriainatleasttheearly
stagesofaddiction.Andrunnersaswellassomeotherdedicated
exercisersoftenascribetheirperseverancetoanaddictiontothe
hightheygetwhentheypushthemselvestotheirverylimit.One
cannotdismissoutofhandwhathascapturedtheimaginationof
somany.Dr.Morganandotherthoughtfulscientistsarenot
convincedthatarunner'shighevenexists,butobjectivitypales
beforethemagicalvistaofwhatMDmagazinecalled"Unity
withnature."(14)
Dr.GeorgeSheehanhasdescribedtheexperiencethisway:
"Ihadjustattackedalonghillontheriverroadandhadbeen
reducedtoaslowjog.Thenithappened.Thefeelingof
wholenessandpeaceandcontentmentcameoverme.Iloved
myselfandtheworldandeverythinginit.Ihadnolongertowill
whatIwasdoing.Theroadseemedtoberunningme.Iwasina
placeandtimeIneverwantedtoleave."(15)
Dr.JohnDeaton,aphysician,writerandrunnerfromAustin,
Texas,commentsthatoneofthemostdesirableaspectsof
runningisthatitcantransportyouagainandagaintothe

"finest"and"trulypleasurable"momentsinlife,moments
"memorablebothfortheirintensityandforthefactthattheyare
soinfrequent."Hisrunninghighislikethe"firstflushof
euphoriathatfollowsthetakingofacentralnervoussystem
stimulant."Which,bytheway,endorphinsarenot.Atother
times,Dr.Deatonmakesrunningsoundakintofallinginlove.
Hebecomes,asheputsit,"flightywithloveandideas....."(16)
Thelureofsuchpoeticimagerycaneasilyoverwhelma
dispassionateviewofwhatispossibleforusmeremortals.
Runnershavesurroundedtheirsportwithwhathasbeenreferred
toasthe"mystiquethatbordersonthemetaphysical."
ACaliforniarunningpsychiatristofferspatientsalterationsin
consciousness,euphoriaand"changesinperceptionsthat
ultimatelyenhanceinsights."(17)KathySwitzer,thefirstofficial
femaleentrantintheBostonMarathon,describesherselfas
"moresensuous...morephysicallysensitiveto...everything."
Notonetoslightintellect,Switzeralsoclaimsthatrunning
makeshermorementallysensitive.(18)Dr.Sheehandescribes
sportsandracingas"heroic,"andreferstothe"millionswhoare
experiencinganescapetotheirhigherselves."(19)
EricOlsen,contributingeditortoTheRunner,writesthat"the
fewsecondsbetweenthereportofthestarter'spistolandthe
finalthrustacrossthefinishline...arerich,andwithinthem
thesprinterwillalwaysfindnewworldstoexplore.The
perceptionssharpenandfocusinonthemomentathand,theold
divisionbetweenconsciousnessandinstinctbeginstobreak
down,andthefleshrespondstothewillwithaclarityand
precisionmostofusrarelyknow."(20)Forwhateverit'sworth,
runnerEvelynAshforddescribesthatsamespanoftimenotasa
"sharpening,""focusing,""clarity"or"precision,"butasa
"senseofunrealness."(21)
Objectivelyspeakingwhichishardinthefaceofsuch
hyperboleveryfewrunners,dancers,jumpers,climbersorany
kindofexerciserseverachieveeuphoria.Thesenseof
omnipotenceandinvincibility,oftotalrelaxationand"Zenlike"
peace,ofeithersharpenedperceptionordreamlikestatesthat

havebeendescribedwilleludeallbuttheveryfew.
Wedon'tunderstandwhata"runner'sshigh"is,what
physiologicalprocessesmightbringitonorevenwhether
exerciseistheonlywaytoachieveit.Butonethingwedo
know:ifexerciseisapathwaytoeuphoria,therewardisbought
attheexpenseofextremesofexertion.
Thebeliefthattherewardofahighsurpassesthepunishment
requiredtoattainitmeansthatyoumustpushyourselfever
harder,beyondtheboundariesofeverydayriskandthelimitsof
prudence.Itdemandsthatyoususpendawarenessofsymptoms,
ofwarningsignalsoffatigueandpain.Thebeliefplummetsyou
towarddanger.

The Exercise Myth by Dr H Solomon

7. The Dangers Of Exercise

Someofthedangersofexerciseareonlyalittlemorebizarre
thanthehazardsofeverydaylife.Runnersinthe1980Peachtree
RoadRace,heldeachJuly4thinAtlanta,Georgia,reporteda
totalof61dogbites,3collisionswithbicyclesand9withmotor
vehicleswhilerunningduringasingleyear.Over100hadbeen
hitbythrownobjects,includingcans,bottles,ice,liquidsand
onebagofrocks.(1)Ofcourse,peoplehavebeenkilledbyfalling
masonrywhilestandingperfectlystill;youcan'tnecessarily
blameexerciseforsnappingdogs,flyingrocks,freakaccidents
andcrazypeople.
Ontheotherhand,overonethirdofthoserunnerssufferedan
injurybroughtonbyrunningalone,andmaybetheyhadtobea
littlecrazytotakethatchance.Thekindsofinjuriesthatoccur
tothemuscularandskeletalsystemsinrunningandother
popularformsofexerciseareaveritablecatalogueof
orthopaedicpossibilities.Inoneextensivesurveyofrecordsof

1,650amateurrunnerswith1,819injuriesseeninjusttwoyears
bytwophysiciansattheUniversityofBritishColumbia,in
Vancouver,doctorsD.B.ClementandJ.E.Tauntonidentified
19typesofinjuriestotheknee,22tothefoot,13tothelower
leg,5totheupperleg,8tothehipand4tothelowerback,as
wellasanumberofadditionalpainfulinjuriestoeachareathat
weren'tdiagnosedmorespecifically.(2)
Injuriesinothersportsandvariouskindsofexercisearealso
common.Arandomsurveyofsquashplayersfromtwosquash
clubs,forexample,founda44.5percentinjuryrateovertheir
yearsofplaying(whichaveragedtwoyearsinonecluband
eightintheother),meaningthatjustunderhalfofallsquash
playersareinjuredwhileplaying.(3)About10percentwere
orthopedic,includingbackinjuries,tornligamentsandtendons,
sprainsandinflammation;theremainderincludedlacerations
andeyewounds.Contrarytopopularbelief,thebetterandmore
experiencedplayersinthisstudyhadmoreseriousanddisabling
injuries.Perhapstheyplayharderandtakemoreriskssomuch
foramateursportsbeing"allinfun."
Theproblemsoftennisplayersarewellknown"tenniselbow,"
shoulder,kneeandleginjuries.Mostarecausedbytheabrupt
stops,turnsandtwistsourjointsareilldesignedtowithstand,
nottomentionthepullsandstrainsthatoccurwhenfancy
manoeuvresdon'tcomeoffwell.Inanattempttopatchthe
damageandcarryon,straps,bracesandbandagesarenow
probablycommonerthanwhiteshirtsandshortsonthetennis
court.
Skiinginjuriesaresocommonthey'repartandparcelofthe
sport.Acollegecampusafterwintervacationoftenlookslikean
orthopaedicclinic.Andmanyanexecutivewearshisplasterasa
badgeofhonour.Orthopaedicsurgeonslovesnowasmuchas
skiresortoperatorsdo.

Dr.JamesNicholas,orthopaedicspecialistinNewYorkCity,
estimatesthat17millionto20millionsportsinjuriesare
reportedeachyear,andthatperhapsanother10milliongo
unreported.(4)Dr.KennethCooper,whoput"aerobics"upthere
withMomandapplepie,estimatesthat60to70percentofall
runnersarehurtbadlyenougheachyeartocutbackorstoptheir
programscompletely.(5)Surveysandstudiesofrunnersshow
injuriesrunningexcusethepunfrom60to90percent.
Runninginjuriesareespeciallycommonbecauseofthe
punishingforceyourbodyhastotake.Theimpactoneach
joggingstepistwotothreetimesyourbodyweight.Onaverage,
yourfeetwillstriketheground800to1,000timespermile.If
youarea150poundrunner,yougenerateandmustendureat
least120tonsofforcepermile.Ifyouruntwotofourmiles
everyday,youfacefrom720to1,920tonsofforceeachweek.
Amarathonermayeasilyfacemorethan3,000tonsinasingle
race.Exposedtosuchstress,it'snowonderthatmuscularand
skeletalinjurieshappensooften.
Kneesarethemostvulnerablepartofarunner'sbody.The
PeachtreeRoadRacesurveydeterminedthatabout38percentof
newinjuriesinvolvedtheknees.Dr.DavidM.Brody,whose
GeorgeWashingtonUniversityrunner'sclinichasexamined
morethan4,000patients,foundthatmorethanonethirdofthe
injuriesweretotheknee.(6)Otherlargestudiesagree.The
commonestinjury,knownas"runner'sknee,"isduetogrinding
ofthekneecapagainstthebonebeneathit.Ifyoucouldseea
kneeinmotionmusclescontracting,tendonsandligaments
pulledtaut,bonesandcartilageslidingandgrindingoverone
anotheryouwouldappreciatemoreeasilyallthatcanhappen.
Itmaybeamiraclethatdamagedoesn'thappenmoreoften.
Thelowerlegsandfeetarethenextmostvulnerableareas.
DoctorsClementandTauntonfound28percentand17percent
ofinjuriesinvolved,respectively,thelowerlegandthefoot,

withvariousformsofinflammationandfractureheadingthelist.
Dr.Brodyalsoreportedthatlowerlegandfootinjuriesare
commonestaftertheknees.Avarietyofotheranatomicsites
thighsandpelvis,forexamplethenfollowaslesscommon
locationsforrunninginducedinjuries.Therecuperativeperiod
fromsuchinjuriesstretchestoweeksandmonths.The
disability,bothacuteandchronic,isoftensignificant.Timelost
fromworkanddirectmedicalcostsmaybeconsiderable.Evena
spraincansidelineyouforweeks;andacompoundfractureis
goingtomakeyouandyourdoctorlongtimebuddies.Of
course,whatconditioningwasgainedfromexerciseisgenerally
quicklylostduringrecuperation.
Mostoftheseinjuriesareavoidable.Runnershurtthemselvesby
runningtoohard,ortoolong,oroverterrainthatistoosteep,
hard,roughorunevenforthem.Otherexercisers,too,gethurt
byliterallythrowingthemselvesintothegame.Damageto
joints,muscles,tendonsandbonesgenerallyresultsfrom
overuse,notfromacutetrauma,suchas,say,anastyfallonan
icypavement.Thepracticesthathurtexercisersarethosethey
chooseforthemselves.Onewouldliketothinktheydoso
becausetheyareuninformedormisinformed.
Lotsofpeopledoinjurethemselvesduringstrenuousexercise
becausethey'reunawareofjusthoweasilyinjurycanoccur.
Theypickupheavyobjectsthewrongway,andstraintheirback
muscles.Theylaunchintoafasttennisgamewithoutwarming
up,andtearastiffmuscleunreadyforforcefulstretching.They
goouttojogfortheveryfirsttime,andanankleunpreparedfor
thepoundingofpavement"gives"astheyturnacorner,ora
tendonpulledforanhourwithoutrestbecomesinflamedand
painful.Knowingthiscanhelpifyou'rewillingtomake
allowancesforthelimitationsofbones,joints,musclesand
tendons.
Whereasit'spossiblethatsomeregularexercisersaretruly

uninformed,anddon'tseeorhearorreadanythingaboutwhat
theydo,runnersinparticulararelikelytohaveplentyof
information.Yetsensibleadviceisoverwhelmedbyan
overridingmessage:runharder,runlongerrunforyourlife.
Dedicatedrunnersreallyadheretothedesperateideathatto
protectthemselvesfromdiseaseanddeath,toattaintheexalted
senseofbeingfullyalive,theymustdrivethemselvesbeyond
painandexhaustion.
Dr.Sheehanboaststhathewon'tallowhisbodytostopeven
thoughheis"runningonempty."Whenhishandsareclawing
theair,hislegsleadenandpainiseverywhere,hekeepsrunning
towardthefinishheso"desperately"desires.(7)Hefindsthe
racethe"moralequivalentofwar,"andhedeemsit"heroic"to
demandofourselvesincredibleeffort"beyonddepthof
exertion."(8)Afamouscoachsays,lesspoetically,"Youhaveto
rununtilithurts."Andanothertellsmethattherealsatisfaction
comesfrom"pushingyourselftoyourlimitandthengoing
beyondit!"
Inthefaceofthissortofencouragement,somerunnerssimply
cannotrunsensibly.Theterm"addiction"hasbeenincreasingly
usedtoexplainthededicationofagrowingnumberofjoggersto
punishingactivity.Dr.WilliamP.Morgan,oftheUniversityof
Wisconsin,claimstheserunnersdemonstratethemajor
characteristicsofrealaddiction.Theywilldoalmostanythingto
getarunning"fix,"andtheyhavewithdrawalsymptoms,such
asdepression,irritabilityandinsomniaiftheycan'trun.
Althoughlessstudied,thesamesymptomsofaddictionhave
beenobservedamongotherexercisers,too.Anexerciseaddict
willkeepongoingevenwhentoldtostop;hewillignorepain
andtakemedicinesorshotstorelieveit.Hemayexercise,says
Dr.Morgan,tothepointwhereinjuriesare"nearcrippling."(9)
Perhapstheterm"exerciseaddict"canbeappliedtoonlyasmall
minority,butafrighteningnumberofexerciseenthusiastsact

contrarytoreasonandcommonsense,asthoughimpelledby
somedemonoftheirowntodisregardthesignalsgivenbytheir
bodies.InasurveyatTorontoWesternHospital'ssports
medicineclinic,whichisavailabletoallcomers,nearlyonehalf
ofthepatientswaitedfivedaysorlongertoseekmedicalhelp
afterbeinginjured.(10)Thelongestdelayswerefoundamong
thosewhosetthehighestpersonalperformancestandards,and
whoregardedtheiractivityaslifeenhancingandhealth
promoting.ClinicdoctorGeoffreyJ.Lloydnotedthatthe
injuredtendedtominimizethepainfulnessoftheinjuryandto
disregardserioussymptoms.Theydidn'tperceiveobviousinjury
assignificant,didn'twanttobelievetheywereinjuredandwere
reluctanttodiscontinueactivitytoallowinjuriestoheal.Even
JamesFixx,authorofTheCompleteBookofRunningandthe
lastpersontodiscourageit,admitsthat"whenarunnercomesto
see[aphysician]withaninjury,it'shislastresort.Hewillhave
triedeverythingelsehecanthinkofthatmightenablehimto
keeprunningincludingprayer.(11)
Ofcourse,fulltimeathleteshavebecomenotoriousfor
continuinginthefaceofinjury.DougPetersen,theOlympic
skier,continuedtoskiforthreeweekswithafracturedvertebra
inhisneck;hefinallyhadtoundergosurgery.Asreportedby
FraserKent,amedicalwriter,hewasquoted:"Deepinside,I
knewtherewassomethingwrong,thatIwasinjured."(12)All
toooften,suchordealsareviewedasheroism.Worse,these
dangerousdenialsbecomeinmanyrecreationalathletes'minds
themodeltheyaretofollow.
Dr.K.WayneMarshall,oftheUniversityofToronto,feelsthat
althoughrecreationalathletesmaymisinterpretthepainsthey
experience,theycompoundignoranceby"macho"stoicism.He
hasfoundthatthosewhoconsistentlyendangerthemselvesby
denyingthesignificanceofpainarealsothosewho"hadset
unrealisticgoals.Theirstrivingtoachievethesegoalsoftenled
toinjury."(13)

AnexampleisJimRyan,atelevisionreporterandavidrunner,
whodescribedhisexperienceinanetworkTVnewssegment.
Hehadfeltpaininonethighaftera10milerun.Hisresponse
wastorun11milesthefollowingday.Afterthat,hecould
barelywalk.
In1979,televisionwatchersweretreatedtotheappallingview
ofPresidentJimmyCarterbeingforcedfroma6.2mileraceby
hisphysician,whosawhimvisiblyfaltering.Andthosewho
followedtheBostonMarathonin1982mayrecallthatthe
winner,AlbertoSalazar,almostdiedofdehydrationandlow
bodytemperaturerightafterhisgreatvictory.SaidFredLebow,
PresidentoftheNewYorkRoadRunnersClub,"Ifthatkidhad
achoiceoflosingordying,hewouldchoosedeath."(14)
Physicians,whocertainlycannotclaimtobeuninformedor
unawareofthedangers,arethemselvesnotimmunetothe
suspensionofcommonsensethatleadstosuchahighincidence
ofexerciseinducedinjuries.AsedentaryNewYorkState
physiciandescribeshowherantheBostonMarathon:"Itrained
intwomonths,butIwouldn'trecommendthat.Ilost60pounds
andwentfromzeromilesto20mileruns.Ilostallmytoenails.
Bloodwasrunningoutofmyshoes."(15)
AnoverweightmiddleagedcardiologistfromWestVirginia
ranthesameracewithastressfracture,cominginlastbut
proud.(16)Andstillanotherdoctor,JohnDeaton,fromAustin,
Texas,decidedtorunanupcomingquartermarathoneven
thoughhewasjustrecoveringfromtheflu.Onthefifthdayof
his"allout"trainingprogram,histemperatureshotupto105.
Heselfdiagnosedarelapseoftheflu,butfourdayslaterwound
uponthehospitalcriticallistwithlobarpneumonia."Themain
danger,"Deatonsays,"isthattheecstasyyoufeelatwhatyou
haveaccomplishedmaylureyoulikeasirensongtodotoo
muchtooquickly,toignorethesoftwhispersofcautionthat
comefromyourbody..,euphoriaandafeelingof

indestructibilitycanoverrideaches,pains,evencommonsense.
Thehurtcomeslater...."(17)
Ifthesearetheexerciseheroes,thensurelyexerciseenthusiasts
beginner,noviceandexpertareinfortrouble.The
machismotintedlensesthroughwhichweseesuchfolly
translatessittingoutthelastsetoftennisorslowingtoawalk
whenjoggingasgivinginandgivingup.Norisdrivingthe
bodyharderthanitcantakeconfinedtowouldbemarathoners,
ortomen.Slowjoggerswhoonlywanttojounceoffafew
poundsandsuburbanhousewiveswhoworryaboutsagsand
bulgeshavejoinedtheinjurystatisticsindroves.Women,in
fact,areparticularlypronetotheirownvarietiesofdamage.
Specialvulnerabilitytoorthopedicinjuryinwomenexists
mainlybecauseofanatomicaldifferencesintheirbones,joints
andmuscles.(18)Womenhaveaslighterbonestructure,with
moredelicateligamentsandtendons.Thestructureoftheir
collagen,thematrixofconnectiveandothersupportingtissues,
isdifferent.Theircenterofgravity,theplacewherethebody
experiencesthegreatestforce,isbetweentheirhipbones,
makingthemvulnerabletopelvicinjuries,whereasinmenthe
centerofgravityisusuallyhigher,betweenthechestandwaist.
Dr.DennisJ.Sullivan,orthopaedicsurgeonattheHospitalfor
SpecialSurgeryinNewYorkCity,foundthatfiveoutofsix
stressfracturesinthepelviswereinexercisingwomenover
thirtyyearsofage,andtherehavebeensimilarreportsof
frequentstressfracturesinwomenfromotherresearchers.
Thewiderpelvisofwomengreatfortheexerciseofchildbirth
butnotforrunningmeanstheirthighbonesstandatanangle
andleanintowardtheknees,causingunequalstressesonthe
insideandoutsideofthekneejoints.Theirkneesaremore
mobileandtheirthighmusclesweaker,sotheirkneesaren'theld
inplacesowell,makingthemvulnerabletokneeinjuries.Even
amongtoprankedtennisplayers,manymorefemalesthan

malessufferkneeinjuries.
Women'snarrowershouldersandchestsmakethemmoreprone
toshoulderdislocationsthanmenare.Generalbodyflexibility,
althoughanadvantagefordancingandgymnastics,addstothe
risksofdislocationandfracture.Andthereistheadditional
elementofinadequatepreparation.ThelateDr.JohnL.
Marshall,famedorthopaedicsportsmedicinespecialist,
suggestedthatthegreaternumberofstrains,sprainsand
dislocationsinwomenwhofirststartexercisingaredue,atleast
inpart,tolesspriortraining.AndDr.HowardA.Kiernan,
orthopaedicsurgeonatPresbyterianHospitalinNewYorkCity,
foundan"epidemic"ofkneeailmentsamongjoggingsuburban
housewives,whichheattributedto"poorconditioning."(19)
Thereisalsothedisturbingpossibilitythatsomethingseriousis
goingonwithinthebonesoffemaleexercisers.Thereisrecent
evidence,forexample,thatwomenrunnersmaylosesignificant
amountsofminerals,suchascalcium,fromtheirbones,and
therebydevelopearlyosteoporosisaconditioncharacterized
bylossofboneminerals,leadingto"softening"ofthebones,
painandvulnerabilitytoinjury.
Thisprematurelossofboneseemstobeintimatelytiedto
changesinfemalehormonefunctioninducedbyexercise.Ithas
beenknownforsomeyearsthatthereareinteractionsbetween
physicalactivityandthemenstrualcycle.Butitisonlysince
womeningreaternumbershavetakenupphysicalexercisethat
hormonechangeshavebeenrecognizedasageneralproblem.
Earliersurveysofwomenathletessuggestedthatabout10
percenthadabnormalmenstrualcycles.Morerecently,as
womenhavebecomemoreinvolvedinyearroundtraining
programs,theoccurrenceofmenstrualirregularitieshas
increased.
It'snotclearjusthowexerciseinduceslossofmenstrual

regularityorevenstopsmenstruationaltogether.Butitappears
thatwhenexerciseinducedlossofweightreducesthefatina
woman'sbodytobelowacertainproportion,variablyestimated
tobebetween17and22percentofhertotalweight,
menstruationisaffected.Womenwhotrainthemostandweigh
theleasttendtohavefewornomenstrualcycles.
Whateverthemechanismforexerciseinducedmenstrual
abnormality,itseemsclearthatthosewomenwhostop
menstruatingdosufferfromosteoporosis,justaswomentendto
doaftermenopause,whenthehormonebalancetheirbodies
havebeenaccustomedtosinceadolescencechanges.Women
withamenorrhealossofmenstruationduetoexerciseseem
tobeasmuchatriskforbonelossasmucholderwomenwould
normallybe.
Theconsequencesofboneslackinginmineralsarefairly
predictable.They'repainfulandtheybreakmoreeasily.Other,
nonorthopaedic,resultsofhormonechangesinducedby
exercisearenotwellunderstood.Certainlyfertilityis
diminishedinwomenwholosetheirperiods,althoughthisisan
imperfectmeansofbirthcontrol,becausesomeathleticwomen
withoutperiodsmaystillovulateandbecomepregnant.
(Incidentally,nounusualproblemshavebeennotedinpregnant
runners.Thereisawonderfultalethathascirculatedthrough
medicalandrunningcirclesofapregnantrunnerwhodidn'tfeel
wellonedayduringarun,discoveredshewasinlabor,andran
theremainingdistancetothehospital,whereshegavebirthtoa
healthybaby.)
Menandwomenareequallyliabletothermalproblemsthe
excessiveheatingorcoolingofinternalbodytemperature.
Whilethermalabnormalitiesdon'tputyouupinplasteror
sentenceyoutocrutches,they'remedicallyalarming.Any
exerciserbalancestheheatgeneratedbyactivitywiththeheat
lostthroughevaporationofsweatandothermechanismsofbody

heatloss.Acombinationofhighintensityexercise,highair
temperatureandhumidityandbodydehydrationcanleadto
overheating,called"hypothermia."Theclinicalexpressionof
hypothermiacanvaryfromrelativelymildheatcramps
characterizedbymusclespasms,throughseriousheat
exhaustion,toheatstroke,whichislifethreatening.With
heatstroketheperson'stemperaturerisestoabove105,his
brainisaffected,sothatheisconfused,deliriousorfallsintoa
coma,followedbycirculatorycollapseandevendeath.Needless
tosay,unaccompaniedexercisersareatgreatrisk;once
confused,theyoftencan'tseekhelp.Whenthetemperatureand
humidityclimbintothe90s,exercisersandthatmeansbikers
andtennisplayersaswellasjoggersshouldprobablytakea
swiminstead.
Theoppositeendofthethermalinjuryspectrumis
"hypothermia,"bodytemperaturethatistoolow.Overcooling
isjustasseriousasoverheating.Whentheweatheriscold,and
lightlycladexerciserssweatheavilyinaprolongedeffort,their
bodytemperaturemaydropmarkedly.Ifbodytemperaturefalls
belowabout90,irrationalbehaviour,lossofcoordinationand
confusionmayoccur;thevictimmay,however,remainunaware
ofhisownsymptomsagainareasontonotexercisealone.In
severecases,respiratoryinsufficiency,cardiacrhythm
irregularitiesanddangerouslylowbloodpressurefollow.
Hypothermia,too,canendindeath.
Afewpeopleareevenallergictoexercise,oratleastarefelled
bythesamesyndrome,called"anaphylaxis,"whichisthemost
seriousallergicreactioninthosewhoaresensitiveto,say,
shellfishorbeestings.Whysomepeopleshouldbringonthis
suddenlossofbloodpressure,swellingofthethroatand
inabilitytobreathesimplybyexertingthemselvesisunknown.
Inareportof16patientssufferinglifethreateninganaphylaxis,
theattackswereprecipitatedbyjogging,running,playing
soccer,basketballortennisandevenbydancing.(20)The

syndromecanoccurwithoutanyprevioushistoryorsymptoms
ofallergy,innoviceaswellastrainedathletes,andtrainingdoes
notdecreasethelikelihoodofitoccurring.
Anotherallergictypereactioniscalled"exerciseinduced
asthma."Thosewithahistoryofasthmamayalreadybeaware
thatbreathingincoldairorexertingthemselvestoomuchmay
bringonthisspasmofthelowerbronchialtubes.About2
percentofthegeneralpopulationhassuchahistory,butalotof
otherpeoplewhohaveneverhadclassicasthmaarealso
susceptibletoasthmaprovokedbyexercise.Althoughany
exertionmayprecipitateit,runningisthecommonest,probably
duetothecoolingofbronchialairpassagesduringrapid
breathing.Someresearchersbelievephysicalexertionitself,
evenwithoutcoolingofthebronchialtubes,maystimulatethe
secretionofaspasmproducingsubstance.
"Runner'sanaemia,"or"sportsanaemia,"deservesmention
becausesomanypeopleareawareofit,andconcerned.It'sa
reductioninthenumberofredbloodcellsandhaemoglobin(the
proteinwithinredbloodcellsthatcarriesoxygen)ofexercising
athletes.
Sincetheredoesn'tseemtobeanythingwrongwiththerunner's
abilitytoproduceredbloodcellsorhaemoglobin,themore
likelyexplanationisthatanexcessivenumberofthebloodcells
aredestroyedduringrunning.Thetraumatothebloodcellsby
feetpoundingonthegroundisthelikeliestexplanation,atheory
supportedbythefascinatingcaseofamanconfinedinamental
institutionwhobecameanaemicbyconstantlypoundinghis
foreheadwithhishands.Someresearchers,ontheotherhand,
believetheanaemiaisaphysiologicaladaptation,which,by
dilutingtheblood,allowsittoflowmoreeasily.Whilerunner's
anaemiaisfairlycommon,it'sgenerallymild,andperformance
doesn'tseemtobehampered.

Exercisersoftenpursuetheirgoalsinspiteofsmallnuisances
likesnifflesandcoughs.Suchgardenvarietyailments,weare
told,willgoawayinsixdayswithtreatment,andinhalfadozen
dayswithout.Unfortunately,awholehostofviralinfections,
includingthecommoncoldandflu,cancauseaninflammation
oftheheartmuscleknownas"myocarditis,"anoftenserious,
smoulderingandpermanentlydamagingdisease.
Thepersonwithmyocarditis,thoughsneezingandachingwith
theusualsymptomsofmildrespiratoryinfection,maybequite
unawarethathishearthasbeenaffected.Whenvirusesfindtheir
waytotheheartmuscle,theyareusuallyfewenoughinnumber
anddon'tmaketheirpresenceknown.Wedonotevenknow
howmanypeoplemayhavehadmyocarditiswithsolittleeffect
atthetimeandsolittledamageremainingthatthediseasehas
neverbeensuspected.
Whenapersonwithmyocarditisexercises,however,virusesin
theheartmusclemaymultiply.Astheyincreaseinnumber,they
causemoreinflammationanddamagetotheheartmuscle.The
moreacutethedamage,themorelikelyispermanentscarring.
Anditisnowbelievedthatmanycasesofotherwise
unexplainedchronicheartfailureweaknessoftheheart
muscleandinabilitytopumpbloodareduetoearlierepisodes
ofviralmyocarditis,perhapsunfeltatthetimeandmanyyears
inthepast.
Thosewho"workoff"minorviralailmentsmaybecourtinga
chronicheartconditionintheirlateryears,andevenanacute,
sometimesfatal,exacerbationofmyocarditisinthepresent.An
exampleisathirtyoneyearoldmanwhowastrainingfora
marathon.Afewweeksbeforetherace,hefelttired,developed
snifflesandmildmuscleachestheusualsymptomsofvarious
"bugs"weareallsusceptibleto.Hecontinuedtorundailyeven
when,threedaysbeforetherace,hebegantoexperiencenausea
andavaguediscomfortinhischestwhilerunning.Bythedayof

themarathonhefeltevenworseandhadtostopat16miles
becauseofchestdiscomfortandvomiting.Hehadacute
myocarditis.
Myocarditisisahappierdiagnosisthansomeotherheart
conditions,formanyrecovercompletely.Buttoexerciseduring
anyviralinfectionisgamblingonthepossibilityofchronic
heartfailureinlateryearsand,duringtheacutephaseofthe
disease,suddendeaththenandthererightontheracecourse.
Mostinjuriesandabnormalitiescommontoavidexercisersare
certainlynot"justwhatthedoctorordered,"buteven
myocarditisisatleastrarelyfatal.Thesameisnotnecessarily
trueofheartattacksandtheyarearealdanger.Cardiac
catastrophe,infact,remainstheoverwhelminglycriticaldanger
ofexercise.Thisissonotonlybecausethefatalityrateishigh,
butbecausetheriskofcardiaccatastropheisnotsoeasyto
avoidastheriskoftendonitisorheatstroke.Peoplewith
coronaryheartdisease,evenofseveredegree,canoften
comfortablyperformatlevelsofvigorousphysicalexertionthat
arenotsafeforthem;thewarningsignalsofimpendingdanger
arenotalwaysdissimilartoinnocuousdiscomforts,andsoare
ignored;andsometimestherearenowarningstoheed.
Ameetingofcardiologistsafewyearsagoheardthatthefirst
astronautwhoeverwalkedinspaceshowedfrightening
abnormalitiesonhiselectrocardiogramthatwastelemetered
backtoearthduringhisextravehicularspacewalk.Sincehewas
superblyfitaccordingtoextensivepreflighttesting,the
physiciansatmissioncontrolheadquartersbelievedthatthe
electrocardiogramwasanaberrationduetothestrange
conditionsinouterspace.Theastronautperformed
satisfactorily,feltwellandpassedpostflighttesting,too;the
medicaljudgmentseemedjustified.Notlongafterward,the
astronautdiedinaspacecapsulefire,andanautopsydisclosed
extensivecoronaryarterydisease.(21)

Notonlyissuperbphysicalperformancepossibleinthe
presenceofseverecoronaryheartdisease,butalsotheperson
mayhimselfnotfeelsymptoms.Iknowpatientsofexceptional
fitnesswhohaveseverecoronaryarterydisease.Evenpeople
withimminentlyfatalheartdiseasecanplaysports,exerciseand
run.Theymayhavenosymptomsandmaybecapableof
outstandingphysicalperformancewithheartsthatwillkillthem.
Moreoften,however,ignoringsymptomsandsignsthatusually
warnofaseriouscardiaceventcontributestothealltoo
frequentoccurrenceofcatastrophesassociatedwithstrenuous
exertion.Anexerciserfeelsshortofbreath,weak,unusually
tired;heascribeshissymptomstoalargebreakfast,abadnight's
sleep,an"offday"orevento"thewall,"asrunnerscallit,that
hemustbreakthroughtogettohiseffortlessstride.Ifhischest
hurts,hisshoulder,hisarmthosearejustthepainsofthe
game.Werethepersonsittinginanarmchairhisalarmmightbe
immediate,butinthemidstofthepoundandsweatofexercise,
heexpectsdiscomforts.Morepernicious,ofcourse,hehasbeen
ledtobelievethatheshouldpushonpastthesesymptoms.And
ifhehasalsocredulouslysubscribedtotheprotectiveeffectof
vigorousactivity,hemaydampenapprehensionwithstrenuous
stoicism.
Allsuchideas,andDr.Bassler'sMarathonHypothesisin
particular,raisefalseandimpossibleexpectations.Andtheykill.
Anyideathatexerciseprotectsfromheartdiseaseleadspeople
toattemptwhattheysimplycannotsafelydo.TheMarathon
Hypothesisgoesfurther,for,inordertoobtain"immunity,"it
asksbelieverstoundergothepunishingregimeofthe26miler.
Notonlyisthatitselfaterribleburdenonasickheart,but
someoneconvincedofhisorherimmunitytocoronaryheart
diseaseisjustthepersonwhowouldneglectandignorethe
warningsignsofimpendingcardiaccatastrophe.
Ofcourse,iftheMarathonHypothesisweretrue,thena

marathonercouldsafelyignorethesymptomsandsignsthat,in
anonmarathoner,wouldsuggestcardiacdisease.Crazily,no
oneseemstorecallthefullstoryforwhichthemarathonis
named.In490B.C.therunnerPheidippidescarriednewsofthe
GreekvictoryoverthePersiansfromMarathontoAthensa
distanceofabout26miles.Upondeliveringhismessage,he
droppeddead.Evidencefromtoday'smarathonersindicatesthat
droppingdeadandfromaheartattackatthatisatleastas
commonamongthese"heroes"asitisamongtherestofus.
DoctorsBruceF.WaIlerandWilliamC.Roberts,ofthe
NationalInstitutesofHealth,inBethesda,Maryland,reported
onfivepatientswhodiedwhilerunning,twoofwhomwere
marathonersandnoneofwhomhadclinicalevidenceofcardiac
diseasebeforebecomingrunners.(22)Allfive,themarathoners
included,diedfromconsequencesofseverecoronary
atherosclerosis.Thefindingssuggest,saydoctorsWaIlerand
Robertswithpoliterestraint,that"Bassler'sthesisthatmarathon
runningprovides'immunitytoatherosclerosis'isincorrect."
Othershavecorroboratedthatfactoflife.DoctorsTimothyD.
NoakesandLionelH.Opie,ofSouthAfrica,reportedautopsy
evidenceofcoronaryatherosclerosisinfourmarathoners.(23)Dr.
RenuVirmani,ChiefoftheDivisionofCardiovascular
PathologyResearchintheDepartmentofCardiovascular
PathologyoftheArmedForcesInstituteofPathology,in
Washington,D.C.,reviewedtheautopsyfindingson7
marathonerswhohadcompletedatotalof64marathons.(24)
Fourdiedofcoronaryheartdisease;theircoronaryarterieswere
foundtobeseverelyaffectedbyatherosclerosis.Dr.Virmani
thenpersonallystudiedautopsiesof3othermarathoners;2of
themhaddiedofseverecoronaryatherosclerosis.Comparingall
causesofdeathamongmarathonerautopsiesshereviewed,Dr.
Virmanifoundthatseverecoronaryatherosclerosisisthemost
commoncauseofdeathinmarathonrunners.(25)
Findingsareaboutthesameforlessdemandingformsof

running,too.
Dr.Virmani,continuingherstudiesofrunningdeathsafterher
initialfindingsfrommarathoners'autopsies,reviewedpublished
reportsofdeathsof57runners,43ofwhomwerejoggers.
Coronaryheartdiseaseoccurredin77percentofthesubjects
andwasthemostfrequentcauseofdeath.Shepersonally
studiedthedeathsof24otherrunners21werejoggers,of
whom13diedwhilejoggingand6soonafterjogging.Twenty
threeofthe24individualshadseverecoronaryatherosclerosis.
(

26)

Oneofthemostimportantstudiesbearingonrunners'mortality
isthatofDr.PaulD.ThompsonandhiscolleaguesatStanford
UniversityMedicalCenter.(27)Theyinvestigatedthe
circumstancesofdeathandthemedicalandactivityhistoriesof
18peoplewhodiedduringorimmediatelyafterjogging.
Fourteenofthe18individualshadexercisedregularlyforoneor
moreyears,9ofthe18forthreeormoreyears.Although4of
the18diedduringcompetition,mostdiedduringtheirusual
exerciseroutines.
Thirteenofthese18exerciserelateddeathsweredueto
coronaryheartdisease.Astheauthor'sstate,"neithersuperior
athleticperformancenorhabitualphysicalexerciseguarantees
protectionagainstanexercisedeath."
Mostofthevictimshadseenaphysicianregularly;exercise
stresstestswerenormalforthreeoffourpeoplewhohadthetest
withintwoyearsoftheirdeath;thefourthwasconsidered
equivocal.Inregardtothevalueofthoroughmedical
examinationsindecreasingexerciserelateddeaths,"our
results,"saysDr.Thompson,"arenotencouraging."
Dr.JeffreyB.HandlerandhiscolleaguesattheNavalRegional
MedicalCenterinSanDiegoreportedthecaseofa48yearold
manwithnoknowncoronaryriskfactors,andwhosetesting

showedhimtobeextremely"fit,"whoneverthelessdeveloped
symptomsofcoronaryarterydiseaseaftereightyearsof
running.(28)Angiogramsshowed99percentblockageofoneof
themajorcoronaryarteries."Documentationofhiscoronary
arterydisease,"saysDr.Handler,"anditsrelationshiptohis
[symptoms]areunimpeachable...thispatientremainsthebest
describedexampleofthefailureofavigorousrunningprogram
topreventtheprogressionofcoronaryatherosclerosis."
Otherformsofstrenuousexercisearenobetteratprotecting
againstheartdisease.Inareportof21athletes,only1ofwhom
wasajogger,Dr.LionelOpiefoundcoronaryheartdiseaseas
thecauseofdeathin18.(29)Otherstudieshavenobetternewsto
add.
Regularexercisedoesnotpreventthedevelopmentand
progressionoftypicalandseverecoronaryatherosclerosis.In
mostinstancesofdeathrelatedtoexercise,infact,coronary
heartdiseaseistheusualfinding.Dr.Thompson,discouraged
thatnoteventhoroughmedicalsurveillancecouldsingleout
thoseatrisk,summeduptheproblem."Exercisedeathsdo
occur,"hewarned,"andthereisnodefinitewaytoidentify
asymptomaticindividualsatrisk.Superiorphysicalfitnessdoes
notguaranteeprotectionagainstexercisedeaths."
Eventheveryyoungmaydieduringexercise,although,unlike
theirslightlyoldercounterparts,whosedeathsareusually
relatedtounderlyingcoronaryheartdisease,thecauseismost
oftenacardiovascularabnormalitytheywerebornwith.Dr.
BarryJ.MaronandhiscolleaguesattheNationalInstitutesof
Healthanalyzedtheheartsof29competitiveathleteswhohad
diedbetweentheagesof13and30years.(30)Twentyfourofthe
29diedduringexertion,andalldiedofoneoranotherformof
unsuspectedheartdisease.Thecommonestcausewas
hypertrophiccardiomyopathy,agenerallyinheritedformof
heartmusclediseasecharacterizedbyunusualenlargementand

disorganzationofheartmusclecells.Therearemanyformsof
cardiomyopathyunrelatedtothecoronaryarteries,heartvalves
oranythingelseintheheartthatmightproducedamage.Not
onlyisthecausefrequentlyunknown,butthediseaseisalmost
asfrequentlyunsuspected.
Evenwhenheartdiseaseannouncesitself,denialofwarning
symptomsisarecurrentthemeinmanystudiesandreportsof
exercisefatalities.Eventhesimpleadviceto"getmoreexercise"
offeredoffhandedlybymanydoctorsmaybeenoughtomake
peopleignorethesignalsthatshouldbeheeded.InDr.
Thompson'sstudyofjoggingrelateddeaths,6of13subjects
whodiedfromcoronaryheartdiseasehadwarningsymptoms
thattheyignored,andnoneofthosewhosesymptomsarosefor
thefirsttimeduringjoggingreducedtheirlevelofexertion.(31)
DerekG.Steward,aformerworldclassathlete,describedhis
ownexperiencewithdenyingthesymptomsofcoronaryheart
disease.(32)Afterabrilliantathleticcareer,heretiredfrom
competitionbutcontinuedtoexerciseregularly.Whenhefound
hisexercisetolerancelowerandexperiencedchestpainwhile
jogging,heinterpretedthesesymptomsassignsof"unfitness."
Hewasnotpsychologicallyprepared,hesays,toacceptthefact
thathewasacandidateforheartdisease.Finally,afterpain
forcedhimtostopafter100yardsofjogging,itbecame
impossibletodenyhistruecondition.
Severecoronaryarterydiseasedevelopedandprogressedinthis
trainingathletealthoughhewascapableofconsiderable
physicalexertionforalongtimewhilehiscoronaryarteries
wereclosingdown.Dr.Bassler'sclaimthatitisbiologically
impossibleforatherosclerosistoprogressinanyonecapableof
evenwalkingthe42kilometermarathondistanceisclearly
untrue.Steward'sexperiencecontradictsit,ashavedoctors
NoakesandOpie,whohavedocumentedtheprogressof
coronaryarterydiseaseduringthelifeofamarathonerwhilehe

continuedtorunmarathons.(33)
Theevidenceisunassailable.Coronaryheartdiseasedevelops
andprogressesduringexercisetrainingandconditioning
programs.Exercisersdieofheartdiseasedespiteexercise.
Butit'sonethingtodiedespitesomething,andquiteanotherto
diebecauseofit.Iftheworstthingthatcouldbesaidabout
exerciseisthatitdoesn'tpreventcoronaryheartdiseaseor
death,thenthosewhoenjoythesweatandthepainwouldhave
noreasonnotto"goforit"assumingthebenefitsoffitness
outweighedtheriskofinjury.
Butpeopledon'tjustdieinspiteofexercise.Theydiebecause
ofit.Andwhetherdeathiswithinseconds,minutesorhours
aftertheonsetoftheterminalevent,thatterminaleventoften
beginsduringorjustafterexercise.
Cardiacdeathsthatoccurhoursorevendaysaftertheonsetof
symptomsareusuallyduetoheartattacks,whereheartmuscle
cellsareinjuredanddieduetoinadequateoxygensupply
throughblockedcoronaryarteries.Deathsthatoccurwithin
secondsorminutes,socalledinstantaneousorsuddendeaths,
areusuallyduetothoseirregularitiesofheartrhythmcalled
"arrhythmias"thataresoseverethattheheartcannoteffectively
pumpbloodaroundthebody.Mostpeoplewhodieof
arrhythmias,likethosewhodieofheartattacks,haveunderlying
diseaseoftheircoronaryarteries.
Observationsthatincriminateexerciseasaprecipitatingfactor
incardiaceventsareoldandestablished.Eventheweatherman
islikelytowarnhismiddleagedorelderlylistenersnotto
shovelsnowafterablizzard.Buttodoastatisticallyproperjob
offingerpointing,researchershavetofigureoutthenumberof
sucheventsthatwouldbeassociatedwithexercisejustby
chance.Chancealonepredictsthatifyousleepeighthoursa
day,sitorwalkaboutforanother15andexertyourself

strenuouslyforonlyaboutanhour,cardiaceventsshouldoccur
inthesameratio:almostallofthemduringsleepingorbeing
mildlyactive,onlyonetwentyfourthofthemwhileexercising
vigorously.
Thedatafromstudiesshockinglyshowotherwise.Suddendeath
wasstudiedinagroupofsoldiers,eighteentothirtynineyears
old,whowereshowntohavecoronarydisease.(34)Fiftyseven
percentofthefatalitieswereassociatedwithstrenuousactivity,
andanother38percentwithmoderateactivity.Notevensoldiers
spend95percentoftheirtimehustlingabout.Inasimilarstudy,
29percentoffatalattackswerecoincidentwithstrenuous
activity,althoughthesubjectsspentonly17percentoftheir
timeexertingthemselvestothatdegree.(35)Theyspentafull
halfoftheirtimeeitherinactiveorasleep,yetonlyaboutathird
ofthefatalattacksoccurredthen.Andinathirdstudy,78
percentoffatalattackswererelatedtoactivity,whileonly22
percentoccurredwithinactivityorsleep.(36)Inall,a
disproportionatenumberofsuddendeathswereassociatedwith
strenuousexertion.
Otherdataconfirmthesameassociationofsuddendeathwith
physicalactivity.Inonecommunitystudy,suddencardiacdeath
wasassociatedwithactivityin80percentofpatients,including
strenuousactivityin20percent.(37)Inanother,Dr.Meyer
Friedman,whohelpedformulateandpopularizetheconceptof
theTypeApersonality,reportedthatmorethanhalfof28
deathsoccurringwithinsecondsoftheonsetofanysymptoms
occurredduringorimmediatelyaftersevereormoderate
physicalactivity,mostnotablyrunningandjogging.(38)"The
closetemporalrelationshipobservedbetweensevereor
moderatephysicalactivityandmorethanonehalfofthe
instantaneouscoronarydeathcases,"saidDr.Friedman,"makes
usquestionwhetheritisworthriskinganinstantaneous
coronarydeathbyindulginginanactivitythepossiblebenefitof
whichtothehumancoronaryvasculaturehasyettobeproved."

Itwasalsodisconcertingthatmanyofthosewhodiedduringor
immediatelyfollowingexertionhadbeenwellaccustomedtothe
specificphysicalactivityinvolved.
Ifexercisehadnospecificcausativeeffectoncardiacevents
ifchancealonedeterminedthecoronarydeathrateduring
exercisethereshouldprobablybeatmostonlyafewhundred
suchdeathsperyear.Whenyoulookatthenumbersactually
reported,thereisadramaticcausalrelationshipbetween
exerciseanddeath,arelationshipthatcannotbedismissed.
Therearedatathatgiveusatruersenseoftheextentofthe
risks.ArecentstudyfromRhodeIslandindicatesthattheannual
coronarydeathratethatwouldincludebothfatalarrhythmias
andheartattacksfromjoggingisaboutseventimesthe
coronarydeathrateduringmoresedentaryactivities.(39)The
prevalenceofjoggingwasdeterminedbyatelephonesurvey
andtheactualincidenceofdeathduringjoggingwasestimated
at1peryearforevery7,620joggers,orapproximately1death
per396,000manhoursofjogging.Ifyouconsiderthat30
millionpeoplejogregularlyintheUnitedStates,theyearlycost
isover3,900lives.
Otherestimatesandcalculationsoftheincidenceofcardiac
fatalitiesduringexerciseareevenhigherthanthosegiveninthe
RhodeIslandstudyofjoggers.Studiesofexerciseprograms
varyallthewayfrom1deathforevery7,000manhoursof
exerciseto1deathforevery55,000manhoursofexercise.
Thereisnodoubtthattheolderthepopulation,andthemore
severetheunderlyingheartdisease,thehigheristhelikelihood
ofcardiaccatastrophe.
OneCanadianstudycalculatedanincidenceof1episodeof
ventricularfibrillation(aquicklyfatalarrhythmia)per2,500
gymnasiumhoursformiddleagedbusinessmen.(40)Ifagroup
ofmeninthatagecategorywereknowntohaveatherosclerosis

oritsriskfactors,theirriskofprovokinganepisodeof
dangerousarrhythmiawhileworkingoutinagymcouldbeas
highas1episodeforevery500hoursofexertion..(41)Ina
reportfromSeattle.Washington,25exerciserelatedcardiac
arrestsoccurredamong1,957menwithcoronarydiseaseina
cardiacrehabilitationprogram..(42)Sinceatotalof374,616
hoursofsupervisedtrainingwasrecorded,theincidenceof
cardiacarrestinthisgroupwasabout1forevery80men,and
almost1episodeforevery15,000manhoursofexercise.Of
greatinterest,themenwhosufferedcardiacarrestwerecapable
ofmorephysicalexercisethanthosewhodidnot.
Whenyoulookatcardiaceventsingeneralnonfatalheart
attacksandarrhythmiasaswellasfatalheartattacksandsudden
deathyoucouldjustifyaclaimthatexerciseisapublichealth
hazard.TheInstituteforAerobicsResearch,inDallas,Texas,
usedstandardequationsforcalculatingstatisticalprobabilityto
estimatethemaximumnumberofcardiac"events"tobe
expectedintheexercisingpopulationasawhole,basedonthe
eventsthathadoccurredinasampleof2,935adultswhoputin
atotalof374,798hoursofexerciseovera65monthperiod.(43)
Dependingontheageoftheexercisers,themaximumrisk
estimatesformenrangedfrom0.3to2.7cardiacdeathsornon
fataleventsforevery10,000hoursofexercise.Theriskfor
womenwasfiguredtobenearlydoublethat,or0.6to6.0events
forevery10,000hoursofexercise.Basedontheirstatistical
equationsandtheirmathematicalcalculations,assumingthat
eachexerciserputsinonlyabout78hoursofexerciseeachyear
(30minutesthreetimesaweek),wecouldexpectthatbetween2
and27ineverythousandmenwouldsuffersomesortofcardiac
eventperyear,andsowouldbetween5and50inevery
thousandwomen.Evenusingthelowestfigures,if20million
menexerciseregularly,wecouldexpect40,000ofthemtobring
uponthemselvesaheartattackorworse;andif10million
womenexerciseregularly,50,000ofthemarealsolikelyto
undergoacardiacevent.Thelowestfigures,ofcourse,relateto

theyoungestexercisers,thoseleastlikelytohaveadvanced
atherosclerosis.
Attemptstopindownthestatisticsinexerciserelatedcardiac
deathsandothercardiaceventsseemtoindicatethat,if
anything,availabledataunderestimatethemagnitudeoftherisk.
Anumberofcardiovascularcomplicationsprobablygo
unrecognizedatthetime,andthereforeunreported.Aperson
mayfirstexperiencesymptomsashepourshimselfabeerafter
alongworkoutorstrollshomefromthegym,andmaynotrelate
ittotheefforthesorecentlyputforth.Apersonmaynotinform
othersoffeelingsofweaknessorevenpainwhileexercising,so
thatthefirsttheyknowofhisconditionissomehourslater
when,apparentlysuddenlyandwithoutanylinktoexertion,he
dies.
Moreover,badnewsislesslikelytobepubliclyreportedthan
goodnews.Inoneattemptatasurveyofcardiaceventsat
communityrecreationcenters,50percentofthefacilitiesfailed
torespond..(44)Althoughwecan'tknowwhethertheirreports
wouldbelessfavourablethanthosefromcentersthatdid
respond,Idoubttheywouldbebetter!
Asforyourindividualchancesofappearingamongthesorry
statisticsofexerciserelateddeaths,thatisimpossibletosay.
Neitherage,norresultsofstresstesting,nordurationofexercise
traininghasanyreliablepredictivevalue.Manypeoplewhodie
throughexertionhavedonethesameactivitymanytimesbefore
withouttrouble.Superiorathleticperformanceoffersno
guaranteeagainstdyingthrougheffort.Perhapsthegambleis
greaterifyouhaveheartdisease,butthereisanenormouspool
ofunrecognizedheartdiseaseinthepopulation.Exercisedeaths
occur,andwecannotidentifytheindividualsatrisk.
Wecansaywithsuretythatifyouchoosetothrowyourselfinto
exercisewiththevigourandabandonenthusiastspromote,some

sortofproblemislikelytoconfrontyou.Itmaybeorthopaedic,
metabolic,hormonalorcardiac;itmaybemildorsevere,
temporaryorpermanent,insignificantorserious.Butstrenuous
exerciseisreallygambling,andyouhavetoweighthestakes
carefully.Doyoustandtogainenoughtooffsetthehazards?
Aretherewardsreallyworththerisks?Mostimportant,isthere
someotherwaysane,sensible,safetoreapthefunof
exercisewithoutharvestingacropofills?Thereis,anditis
availabletojustabouteveryoneofus.

The Exercise Myth by Dr H Solomon

8. A Better Way
Thisisnotanantiexercisebook.It'ssimplytheothersideofthe
exercisestory,thesidefewpeoplehaveheardandsomedon't
wanttoknow.Thefactsdon'tobviatethepleasuresofexercise,
buttheydosayexerciseisdangerouswhenit'sdoneforthe
wrongreasons.Thetruthcanprotectyoufromtheclaimsand
aimsofothers,and,perhaps,fromyourself.Youcan'texercise
foryourhealth;youcan'trunforyourlife.Butyoucanexercise
forfitnessandforpleasure,andyoucandoitsafely.
Almostanyformofexertioncanbekeptatasaferlevelifyou
don'tdriveyourselftooverdoit.Withtheexceptionof
inherentlybonebreakingcontactsportssuchasfootballand
boxing,whereinflictingpainanddamageonyouropponentis
necessaryforwinning,evenaccidentriddenactivitiessuchas
skiingandrunningcanbedonewithlessriskofinjury.Takea
lessdemandingslope,forexample,ortrycrosscountryskiing
insteadofdownhill.Ifyoumustcoveralotofgroundtoenjoy
yourself,trot,don'trun.Cushiontheimpactonyourjointswith
goodsneakersandseeifyoucanfindasoftrunningsurface
suchasasmoothdirtpathinsteadofharshorunevenpavement.
Therearepublishedprecautionsforeverysportthatisbesetby

muscularandskeletalinjuries;riskcanbeminimizedifyou're
willingtoeducateyourselfinprudence.
Moreworrisomethanorthopaedicrisksarethedangersof
cardiaceventswhileperformingallkindsofactivities.Toavoid
these,theultimaterisks,thereisonlyoneprecautionthatmakes
sense:Don'tdoanythingtothepointwhereyoufeelexhausted,
undulywindedorhavepainordiscomfortinoraroundyour
chest.
It'ssmartesttoplantolimityourexertionfromtheoutset.That
meanslongdistancerunningisnotinthecardsformostofus.
Joggingmaybeallright,butonlyifyoudroptoawalkthe
momentyourbodytellsyoutoslowdown.Ifbasketballisyour
game,halfcourtholdsmostoftheexcitementandchallengeof
offenseanddefensewithouttheexhaustionofrunningupand
downthelengthofthefullcourt.Planathreesetratherthana
fivesettennismatch;itoughttobesufficientlyexhilarating.
Andifyou'retired,sitoutthethirdset.Later,ifyouwantto
playagain,howaboutdoubles?Planningyourexercise
prudentlybeforeyoustartwillhelpyouavoidgettingintoa
situationwhereyoususpectyoushouldstopbutthepressuresof
sociabilityandcompetitionmakethatsensibledecisionappear
gaucheatbest,cowardlyatworst.
Thereisasubtlebutcrucialdistinctionbetweenplanningyour
activitytoavoidgettingintoapredicament,andexerting
yourselfuntiltheonsetofsymptomsoccurs.Warningsignalsdo
precedemanydisasters,butbythetimeyourbreathingis
labored,yourchesthurtsorfeelsheavyoryou'relightheadedor
faint,youmayalreadyhavegonetoofartopreventanexercise
catastrophe.Usuallythereisstilltimetopullbacktoasafer
levelofexertion;sometimesthereisn't.
Evenhavingreachedthepointatwhichsymptomsarefelt,it's
stillsometimesdifficulttostop.Intheheatofactivity,when

yourownenthusiasmorothers'eggsyouon,riskmayseem
remote.It'sjusttooeasy,runningtheroadsofyour
neighbourhoodorengagingyourfriendsinfastpacedvolleying
atthecourts,toputdangeroutofyourmindandignorewhat
youmight,underothercircumstances,feelquitealarmedabout.
Aches,painsandheavybreathingareexpected;they'realltoo
easytodismissinthepleasuresandstrivingofthemoment.
Ignoringsuchsymptomsiscourtingcatastrophe.Denialof
warningsymptomsisarecurringthemeinthestudiesand
reportsofexerciseinjuriesanddeaths.Experiencedathletesand
novicesalikeareguiltyofsuchimprudentdenial,andtheyare
equallylikelytosufferfromit.
Then,too,althoughrealtroubleisoftenprecededbywarning
symptomsthatcanberecognized,that'snotalwaysso.Injuries,
heartattacks,evendeathmayoccursuddenlyandwithout
warning.Thealloutexerciserhasnodefense.Suchcatastrophes
areunpredictable;priortrainingandexerciseexperienceoffer
noprotection.Toexercisevigorously,topushyourselfto
greaterandgreaterlimitsbecauseyouhavenosymptoms,isto
subjectyourselftounpredictableandunheraldeddisaster.By
planningamoremodestlevelofexerciseyouhelpyourself
remainonthesideofsafety.
Someassumethatwhentheyareenrolledinaplanned,
prescribedorsupervisedexerciseprogramtheycansafely
abrogatetheresponsibilityfortheirownsafety.Theyfeelthey
needn'tworryaboutoverdoingit,sincethelevelofexertionhas
beenchosenforthembyothers,whomusthaveascientificbasis
forthechoice.Others,howeverexperttheymaybe,can'tfeel
whatishappeninginsideyourbody.Theycan'tknowhow
much,howfarandhowlongyoushouldexerciseonanygiven
day.
Inanyexerciseactivity,supervisedornot,prescribedorself

chosen,yourbestguidetothesafetyofwhatyouaredoingis
yourownselfawareness.Aimingforapredeterminedduration
ofexerciseorapreselectedtargetheartrateisfoolishifyour
bodytellsyouthatyou'reoverdoingit.Thepleasureofworking
upagoodsweatmaybejustaseasilygainedataheartratethat
is,say,50percentofyourmaximumasitisat70percentor
someotherarbitrarilychosenlevel.Andfitnesscanbeachieved
withlessintensityofexertionthantherigidtimeandeffort
schedulesoutlinedinsomanyfamiliarbooksandarticleson
exercise.Professionalathletesneedtoadheretomorerigidly
prescribedandsevereexerciseprograms.Theirlivelihoods
dependonit,andtheyaccepttherisksoftheiroccupationsas
mightacoalmineroranairplanepilot.Recreationalathletes
needn'tandshouldn't,becausethegainsareillusoryandthe
risksalltooreal.
Sensibleexercisersespousethisidea:Listentoyourbody.This
takesabitofpractice;youhavetothinkabouthowyoufeel.
Yourbodywillspeaktoyouinbothgeneralandspecificterms.
Youknowmoreorless,ifyousimplythinkaboutitandyou
shouldthinkaboutitwhetheryouhaveageneralfeelingof
wellbeingornot.Ifyoufeelsickinageneralway,ifyouhavea
sensethatyouaren'twell,yououghtatleastnottoexerciseuntil
thatfeelinggoesoritscauseisdeterminednottoberelatedto
yourphysicalhealth.Justbecauseyoucan'tpinpointaspecific
acheorpainorothersymptomdoesn'tmeanthateverythingis
allright.Ifyoufeelyou'rejustnotright,orareunusually
fatigued,indulgethatfeelingandstopwhatyou'redoing.
Generalfeelingsaboutyourselfareimportantandworth
listeningto.Asyouexercise,thinkperiodicallyabouthowyou
feel.Appropriateexerciseshouldn'tmakeyoufeelsickinany
way.
Specificsymptomsareperhapshardertointerpretbecausewith
exerciseyouexpecttobreatheharder,tofeelyourheartpump,
tohaveyourmusclesachesomewhat.Thebestguidelineasto

whatisnormalandwhatmaysignaldangerisyourown
experienceofhowyourbodyhasusuallyrespondedtoexertion.
Ifyouthinkyou'rebreathingharderthanseemsappropriatefor
anaccustomedactivity,forexample,andespeciallyifyoufeel
uncomfortablebreathing,stoptheexercise.Painsinareasnot
directlyinvolvedinexerciseanachingleftarminaright
handedtennisplayerarealsocausetostop.Ontheotherhand,
ifyoufeelmildpaininthemusclesyou'reactuallyusingduring
thatexercise,it'sprobablysafetoignoreit.Certainlyifyour
chesthurtsandyouhaven'tbeenhitdeadcenterbyasmashat
thenet,youshouldquitonthespot.Infact,anychest
discomfortpain,pressure,tightnessoranyunusualsensation
shouldbeasignaltostopexercising.
Manycommittedexerciserstaketheirpulseasawayof
measuringtheirheartrateatintervalsduringaworkout.Ifyou
takeyourpulse,itshouldn'tbeforthepurposeofincreasing
youractivitytoachievesomearbitrarytraininglevel,butto
keepyourselffrompushinganywherenearyouragepredicted
maximum.Usingtheconvenientformulaforyourpredicted
maximumheartrateof220minusyourage,youcantellhow
closeyouaretothatpointatanytime.Asageneralruleeven
ifyourhealthisexcellentdon'texerciserecreationallyabove
about75percentofyourpredictedmaximumheartrate.Ifyou
haveheartdiseaseandyouknowataboutwhatheartrateyou
oftengetsymptoms,youshouldkeepyouractivityatsucha
levelthatyourheartratestayswellbelowit.Ofcourse,
medicationsmaychangethisrelationshipofsymptomstoheart
rate,andthisisamattertodiscusswithyourphysician.
Besidestherateofyourheart,checkingyourpulseisusefulto
detectanyirregularitiesintheheartrhythm.Somepeoplehave
irregularheartsnormally.Exercisemayhavenoeffectoritmay
evenabolishtheirregularity.Butsomepeopledevelop
irregularitiesonlywithexercise,ortheirbasicirregularityatrest

increasesastheybecomemoreactive.Thesecanhaveserious
implicationsandareotherreasonstoconsultyourphysician.
Mostexercisersaretaughttotaketheirpulsebyfeelingthelarge
pulsatingarteryintheneck,thecarotidartery.Althoughthe
carotidpulseisstrongandeasytolocate,pressingonthatartery
cancauseasuddenreflexslowingoftheheartandafallin
bloodpressurethatleadstoablackout.Occasionallyexercisers
pressbothsidesoftheneckatonceintheirconcerntotaketheir
pulse.Pressingonbothcarotidarteriesnotonlycausesamore
severeslowingoftheheart,butalsoeffectivelycutsoffthe
bloodflowtothebrain.It'sreallybettertotakeyourpulseat
yourwrist,feelingfortheradialartery,andthisisn'thardto
learntodo.
Althoughlisteningtoyourbodyputsyouincommandof
yourself,stoppingwhensomethingalertsyouthatallisnotwell
willnotendearyoutotheexerciseenthusiasts.Theywillurge
youon,tellyouthatyoucandomoreandexhortyouto"gofor
it!"Whenyoupersistinslowingdownorstopping,you'llearn,
nottheirpraiseforyourgoodjudgment,buttheirdisdainfor
yourcautiousness.
Thisisn'teasytobearupunder,butjustrememberthat
exercisersoftenurgeonothersbecauseofignorance.Theydon't
knowthedifferencebetweenfitnessandhealth;youdo.They
believethepromisesoflongevityandbettercardiacandmental
health;youknowbetter.Spectatorsgratuitouslyurgeyouonfor
thevicariousthrillofsomebodyelseachievingadifficultgoal.
Marathoners,forexample,knowthecompellingforceof
spectatorscheeringandexhortingthem.Andthosetowhom
exerciseisbusinessencourageyouonwardbecauseit'smoney
intheirpocket.Whyshouldyoubetheirpaycheck?The
strengthtoresisttheurging'sofothersanddesistfromexercise
shouldcomefromknowingthatyou'renolongeravictimof
myth,aninnocenttakeninbyyourowncredulityorbyothers'

claimsonyou.
Thepressurestoconformtoorganizedexerciseprograms,
especiallythosesupportedwithinacorporation,canbe
unusuallyintense.Acorporationwithafulltimefitnessdirector
reportingtothepresidentismakingastatement:itiscommitted
toexercise,itexpectsyoutobe,too.Whenthecompanyspends
moneyforequipmentandtechnicalapparatus,whenitpaysa
heftysalarytoaspecialisttoorganize"scientific"exercise
regimensorcontractswithoutsidefacilitiestodothesame,your
choosingnottojoinissaying,ineffect,thatyouknowbetter
andthatthey'rewastingtheirmoneyandyourtimeandeffort.In
acommunitywheremostpeopleparticipateinanorganized
exerciseprogram,thosewhochoosetostandaloofmayfind
themselvesstanding"out"inotherareasaswell.
Yetonceyouassumecontrolofyourself,knowyourownbody
tobethebestguidetoyourownlevelofactivityandnolonger
allowotherstosetyourpaceandgoals,youmayfindthatthe
wholegunghoatmosphereoforganizedexerciseprogramsno
longerappealstoyou.Youmaybegintoquestionthewhole
basisofsuchprograms.Whatisthereaboutaparticularroutine
orspecialapparatusthat'sbetterthanalessspecial,lessrigid
formofexercise?Whyshouldyousubmityourselftogroup
pressureortoan"expert's"pseudoscientificmonitoringof
progresstowardanarbitrarygoal?Theirplannedandsupervised
activitiesaren'tanybetterthanyourownsensibleplansfor
exercise.Andtheirgoalsforyoursupposedgoodhealthmake
farlesssensethanyourownwishtobemorefit,toloseweight
orjusttoenjoyyourself.
Therearetwowaystocombatcorporateorcommunitypressure
toparticipateinstructuredexercisewithoutlosingesteemor
appearingnegativeorapathetic.First,offeryourknowledge.
Fitnessdoesproducephysiologicalchanges,buttheyarenot
onesthatmakethehearthealthier,orthatimprovecoronary

circulation.Fitnessisnotrelatedtohealthatall.Heartattacks
aren'tpreventedbyexercise;exercisemayprovokeheart
attacks.And,ifpleasureisthegoal,thereareotheractivitiesyou
prefertogroupexercise.
Second,selectanddefendyourownformandchoiceofactivity.
Whatisyourgoal?Itmaybemerelytoperformthatamountof
exercisethatwillpreventthesmallriskentailedinasedentary
life,oryoumaywishtoretainaleveloffitnessyouarenow
enjoying,orreachforimprovedfitness.Youmaywantonlyto
loseafewpounds.There'snothingwrongwithanyofthese
goals.
Asfortheformofactivity,theidealexerciseshouldbea
rhythmicandrepetitiveactivity.Itshouldusethelargemuscle
groupsofthebody,especiallyofthehipandpelvicareas,in
smoothandcontinuousmotion.Itshouldbesimpletodoand
requirenospecialtrainingorequipment.Itoughttobe
inherentlyeasytopace,onethatcanbedonequicklyorslowly,
forlongerorshorterdistancesandtimes,andatyourown
convenience.Ideallyyoushouldbeabletodoitalmost
anywhere,andaloneorincompany.Itshouldbepleasantandit
mustbesafe.Andifitcostsnothing,allthebetter.
Swimmingalmostmeetsthesecriteria.Theonlyequipmentyou
needisabathingsuitandatowel(skinnydippingreduceseven
theseminimalrequirements).Theactionusesthelargemuscles
oftheshouldergirdleaswellasthoseofthehipsandlegs.The
motionisasmoothone,andthereislittlechanceofinjuryfrom
awkwardmoves,suddenstopsortwistingturns.Thereisno
poundingorwrenchingpressureonanypartofthebody.And,
althoughyoucansink,youcan'tfall.
Butswimmingisaspecialskill,andmanypeoplearen'tgood
enoughatittogetanybenefits.Itoftenisn'tconvenientandit
frequentlycostsmoney.Evenifthereisapoolnearhomeor

office,thereisadiscouraginginconvenienceaboutpackingup,
gettingthere,changing,showeringandthenreturningwithawet
bathingsuit.Swimmingmustbescheduledtofitinwithother
aspectsofyourlife,andthatisn'talwayseasy.
Calisthenicsandaerobicdancinghavetheadvantagethatthey
canbedoneathomeandatanytimeconvenienttoyou.
Callisthenics,however,usuallyfallsshortofhavingatraining
effect.Therewillbesomegainsinstrengthandlimbernessbut
theusualstartandstopmotionofcallisthenicsisnotcontinuous
enoughtoimproveaerobicfitness.Aerobicdancingcallsfor
continuousrhythmicmotion,andthereforecanincreasefitness.
Boththeseformsofexerciseappealtosomebecausethereare
"exercisealong"programsontelevisionandtapecassettesthat
directthemovementsandsetthepace.That'sanotherproblem.
Thespeedandvigoururgeduponviewersorlistenerscan
subjectthemtomuchthesamerisksthatrunningwould,
althoughtheyareatleastonsafergroundintheirownhome.If
you'dliketogetthefitnessbenefitsofaerobicdancing,use
instructionforlearningthemotions,butdancetoyourown
musicslower!Turnoffthemusicbeforeyoufeeltired;don't
waituntilsomearbitrarylengthoftimehaspassed.
Bicycling,too,isanexcellentexerciseandhastheadded
practicalityofgettingyousomewhere.Manychoosetogoto
workbybicycle.Thoughbicyclingisacontinuous,rhythmic
motionthatusesthelargelegmuscles,it'shardontheknees.By
thetimemanypeopleareintheirfortiesorfiftiestheirkneesare
somewhatarthriticfromnormalwearovertheyears.The
additionalstressfrombicyclingcandamagethejointfurtherand
canmakewhatmighthavebeenoccasionaldiscomfortintoa
realmedicalproblem.Bicyclingisprobablyabetterwaymainly
foryoungpeople.
Theaccidentstatisticsforbikersoutonthestreetsandroadsare

alsodiscouraging.Forthatreason,somewhoenjoythemotion
ofpedalingandwhosekneescantakeituseastationarybicycle
inthesafety,privacyandyearroundcomfortoftheirhome.
Exercisebicyclesofferyoucompletecontrolofhowmuchto
exercise,becauseyouaretheonewhodecideshowlong,how
fastandhowhardtopedal.Isuggeststartingbysettingthe
machinetonopedalingresistanceatall,pedalingslowlyatfirst
andincreasingthetimefromperhapsonlyaminutetoabout15
or20minutes.Thenthespeedcanbeincreased,givingyouthe
satisfactionofwatchingmoremilesregisteredpersession.
Whenyou'recomfortablewith15minutesorsooffairlyrapid
pedaling,youcangraduallymaketheworkharderbyincreasing
theresistance.
Theidealexerciseinvirtuallyeveryrespectiswalking.
Certainlynothingcouldbemoreconvenient.Walkingrequires
nospecialtrainingonceyou'velearneditasababy.Anyclothes
willdo.Youcandoitanywhere,eveninthehouse,althoughthe
routemaygetboringandyou'llwearagrooveintherug.You
canenjoythecompanyofothers,sinceyoudon'trequireyour
lastbreathjusttokeepgoing.Walking,likeswimming,usesthe
correctlargemusclesforconditioning;andifyouswingyour
armsfreelyandnaturally,yougetadditionalbenefitsthatway.
Yourpaceisobviouslyeasilyvaried,andyoucanadjustit
instantaneously.
Thetroublewithwalkingisit'ssoeasy.It'ssonaturalthatit
doesn'tseemlikeexercise,andit'shardthereforetoenvisionit
asbeneficial.Well,itdoesrequireabitofspecificdirectionto
makewalkingreallyusefulandworthwhile.Doneregularlyand
atagoodpace,conditioningcanbeachievedsothatthebody
respondstoreasonablephysicaldemandswithease,without
excessiveheartrateorbloodpressureresponsesandwithout
unusualfatigue.
Theamountofwalkingandthespeedyouneeddependonwhat

yourgoalis.Youmaywishonlytoeliminatetheverysmallrisk
ofatrulysedentaryexistence.Sedentaryreferstoalifestyle
virtuallydevoidofallbuttheminimal,unsustainedphysical
activityneededtowalkfromoneroomtoanotherinahouseor
office,orfromhousetocarandgaragetooffice.Evensuch
profoundinactivityconfersbutasmallriskforcoronaryheart
disease;physicalinactivityisatthebottomofthelistof
secondaryriskfactors.Suchdataastherearegenerallysuggest
thatthemajorriskdifferentialforcoronarydiseaseisbetween
virtualinactivityandonlymildtomoderateactivity.Doing
morethanmildtomoderateactivitydoesn'treducetherisksany
further.Althoughtheamountofphysicalactivitynecessaryto
undowhateverriskiscreatedbyinactivityisprobablysmall,the
actualamounthasn'tbeenmeasured.
Asanempiricjudgment,Ihaveforalongtimerecommendeda
dailyminimumofonemileofcontinuouswalkingatapaceof
threemilesperhour,whichtranslatesintoamileintwenty
minutes.Ifpeoplecandothattwiceaday,Iencourageit.ButI
believethattheoncedailyscheduleismorethansufficientto
overcomethesmallriskofasedentaryexistence.Youcanbe
safefromfheriskofasedentarylifewithoutbeingcapableof
runningatall.
Athreemileperhourpaceisnotrunning,butit'snotsauntering
either.Itdoesn'tallowforalotofwindowshopping,butneither
doesitmeanyouhavetoworkupalatherofsweat.It's
comfortable,indeedofteninvigorating,formostpeople.Some,
particularlythosepeoplewhohavebeeninactiveforatimedue
toeitherillnessorpersonalpreference,findthetwentyminute
mileabitsevere.Iencouragethemtoaimfirstforthedistance,
thenthespeed.Inotherwords,goforamileatwhateverrateof
walkingiscomfortable;onceyouachievethedistance,thenpick
upthepace.Morethanamiledistanceandaspeedfasterthan
threemilesperhourareunnecessary.

Ifyourgoalistobecomefit,howmuchwalkingmustyoudo?
Thatdependsonwhatleveloffitnessyouwanttoachieve.A
twentyminutemiletwiceadaycan'ttrainyouforthesuperb
speedandstaminaofanathlete.Butifyouwanttodoallthe
routineactivitiesofdailylivingcomfortably,thenyoudon't
needmore.Youcanincreaseyourfitnessoverawiderangeby
increasingthedistanceandspeedyouwalk,andbychoosingto
includehillsandsteps.Afourmileperhourpace,equivalentto
amileinfifteenminutes,isquiteabriskwalkfasterthanthat
isvirtuallyjoggingandwillcertainlyenhancefitness.The
pointisthatbystayingwithintherelativelysafeconfinesof
walking,youcanachieveallthedesirablegoalsshortofhigh
levelathleticfitness.
Remember,youcanwalkanywhere.Theoutdoorsisgreat,but
ininclementweatheryoucandoitindoors.Someofmypatients
walkinthehallsandlobbiesofapartmentbuildings.In
suburbia,enclosedshoppingmallsareanexcellentplacefor
winterwalking,andindeedforsummerwalkingaswell,when
theoutsidetemperatureandhumidityaretoohigh.Becausethe
paceisn'tsodemanding,andotherscandoitcomfortablywith
you,itcanbemostenjoyable.Companyandconversationare
easy,andthesightsandsoundsaboutyoucanbesavoured.And
ifyoureallyhavesomeplacetogo,youcan"exercise"your
waytowhereyouwanttobeandnoshowerorchangeof
clotheswhenyouarrive.
Walkingistheperfectexerciseforthosewhohaveheartdisease.
Manycardiacpatients,particularlyafteraheartattack,are
frightenedofanyactivity;theylimitthemselvesunduly,narrow
theirhorizons,sometimesmakedrasticchangesintheirlives
thatleavethemfeelinguseless,invalidedanddepressed.
"Cardiacrehabilitation"programshavebecomepopularasa
meansofundoingtheseusuallyselfimposedrestrictions,but
whilesomeindividualsenjoythecamaraderieofgroupsessions,
manypeopledon'twanttobelumpedtogetherwithother

patientsandmayresentregimentation.Theremaybeno
programataconvenientdistanceanyway.
Walkingwillservethesamepurpose.Itisjustaboutthesafest
activityyoucouldthinkof.Anyonewhohasdifficultyduring
theearlystagesofawalkingprogramisprobablydestinedto
havetroubleevenifheorshedoesnothing.Almostallcardiac
patientswhoarefrightenedofexertingthemselvescanactually
domorethantheydo.WhenIstartthemonawalkingprogram,
Isettheinitiallimitssolowperhapsoneblockatwhatever
pacetheywantthattheyareeasilyachieved.Just
accomplishingthislittlebitofactivityisoftenupliftingforsuch
patients.Ithenaskthemgraduallytoincreasethedistanceand
thenthepace,alwaysmoregraduallythanIthinktheyprobably
cando.Istressthatthereisnorushtoachieveanypresetgoals
thereislotsoftime,andtheemphasisisonlongterm
achievement.Aspatientsincreasetheiractivitywithout
disablingsymptomsthechangeinthemisoftenremarkable.
Theirconfidencesoars,theyregaininterestinworkandsexual
activity,theythinkabouttravelingandusuallytheyreturnto
alltheseactivities.
Thereisnomysterytoexercise.Youdon'thavetobeinitiated
intomembership,tobelieveinesotericclaims,topractice
arcanerituals.Whateverbenefitsthehumanbodyderivesfrom
exertionareyourswheneveryoutakeagoodbriskwalkor
enjoyyourselfwithoutpushingyourselfatsomeothersport
youenjoy.
Andifyoucanespousethesaneviewofexertionasfullyas
othersespousetheexercisemyth,you'llbedoingaworldof
goodforothersaswellasforyourself.Ifyoucanmakeinroads
ontheillusorybenefitsofvigorousexercisewiththosewho
havebeenseducedorcoercedintowastingtheirmoneyand
effortandlavishingtheirhopesonit,youwillbehelpingto
checkadangerousandfoolishfad.Ifyoucanconvinceafriend

thathehasnobetterchanceoflivingtoaripeoldagethanyou
bysprintingpastyoueachmorning,oraspousethathisorher
strenuousexerciseregimenismorelikelytobeadangerthana
benefittotheheart,youcouldevenbesavinglives.Indeed,the
exercisemythmaybethefirstpublichealthmenacethatcanbe
combatedwithouttheexpenditureofanymoneyatall.Thefacts
arein;informationisavailable.Theexercisefadisafollyanda
danger.Itonlytakesyoutospreadtheword.
Dr Henry A. Solomon, M.D.
Now(1984)practisescardiologyinNewYorkCity,whereheis
onthefacultyofCornellUniversityMedicalCollegeandan
attendingphysicianatNewYorkHospital.Helectures
frequentlyandpublishesnewslettersdirectedtocolleaguesand
tocardiacpatients.